Alcohol Problems


Some Topics

Alcoholism Abstracts

Nutrition and alcohol neurotoxicity.

Author Manzo L; Locatelli C; Candura SM; Costa LG
Neurotoxicology, 15: 3, 1994 Fall, 555-65

Abstract Neurological complications of alcoholism such as Wernicke-Korsakoff syndrome and polyneuropathy often originate from interactive factors involving direct nervous system toxicity of ethanol and nutrient deficiencies associated to heavy drinking. Not all patients are equally susceptible to these disorders and a genetic predisposition to thiamine deficiency has been described in subjects with Wernicke's encephalopathy. At moderate alcohol dosages, nutrient abnormalities may be marginal, inducing no obvious manifestations until other neurotoxic agents are absorbed. Examples are presented illustrating the interaction of ethanol and styrene on brain glutathione metabolism in rats, and cases of methanol poisoning in alcoholics. In these patients, ethanol-induced folate deficiency can potentiate visual toxicity of methanol due to impairment of the folate-dependent pathway involved in formate detoxication. The notion that nutritional deficiencies and ethanol toxicity may act synergistically in the nervous system outlines the importance of adequate nutritional strategies in the treatment of alcoholism and also indicates that methodological flaws may result during experimental studies from failure to control for nutritional variables.

Mechanisms of ethanol-drug-nutrition interactions.

Author Lieber CS Address Alcohol Research and Treatment Center, VA Medical Center, Bronx, NY 10468. Source J Toxicol Clin Toxicol, 32: 6, 1994, 631-81

Abstract Mechanisms of the toxicologic manifestations of ethanol abuse are reviewed. Hepatotoxicity of ethanol results from alcohol dehydrogenase-mediated excessive hepatic generation of nicotinamide adenine dinucleotide and acetaldehyde. It is now recognized that acetaldehyde is also produced by an accessory (but inducible) pathway, the microsomal ethanol-oxidizing system, which involves a specific cytochrome P450. It generates oxygen radicals and activates many xenobiotics to toxic metabolites, thereby explaining the increased vulnerability of heavy drinkers to industrial solvents, anesthetics, commonly used drugs, over-the-counter medications and carcinogens. The contribution of gastric alcohol dehydrogenase to the first pass metabolism of ethanol and alcohol-drug interactions is now recognized. Alcohol also alters the degradation of key nutrients, thereby promoting deficiencies as well as toxic interactions with vitamin A and beta-carotene. Conversely, nutritional deficits may affect the toxicity of ethanol and acetaldehyde, as illustrated by the depletion in glutathione, ameliorated by S-adenosyl-L-methionine. Other supernutrients include polyenylphosphatidylcholine, shown to correct the alcohol-induced hepatic phosphatidylcholine depletion and to prevent alcoholic cirrhosis in non-human primates. Thus, a better understanding of the pathology induced by ethanol has now generated improved prospects for therapy.


Thomasson HR, Crabb DW, Edenberg HJ, Li TK:

Behavior Genetics 1993; 23(2):131-6.

Summary: The alcohol-flush reaction occurs in Asians who inherit the mutant ALDH2*2 allele that produces an inactive aldehyde dehydrogenase enzyme. In these individuals, high blood acetaldehyde levels are believed to be the cause of the unpleasant symptoms that follow drinking. We measured the alcohol elimination rates and intensity of flushing in Chinese subjects in whom the alcohol dehydrogenase ADH2 and ALDH2 genotypes were determined. We also correlated ADH2, ADH3, and ALDH2 genotypes with drinking behavior in 100 Chinese men. We discovered that ADH2*2 and ADH3*1, alleles that encode the high activity forms of alcohol dehydrogenase, as well as the mutant ALDH2*2 allele were less frequent in alcoholics than in controls. The presence of ALDH2*2 was associated with slower alcohol metabolism and the most intense flushing. In those homozygous for ALDH2*1, the presence of two ADH2*2 alleles correlated with slightly faster alcohol metabolism and more intense flushing, although a great deal of variability in the latter was noted. [References: 25]

GENETIC MODELS IN THE STUDY OF ALCOHOLISM AND SUBSTANCE ABUSE MECHANISMS. George FR: Progress in Neuro-Psychopharmacology & Biological Psychiatry 1993; 17(3):345-61.

Summary: 1. Vulnerability to substance abuse is an important emerging issue. Some related factors are the relationship between propensity to self-administer a drug and neurosensitivity to that drug; similarities and differences between various models of drug seeking behavior; and the commonality of drug-seeking behavior across drugs and genotypes, that is, whether reinforcement from and abuse of alcohol and other drugs define variations within a single behavioral phenomenon, or whether reinforcement and abuse must be individually defined for each substance involved. 2. Findings related to these issues are now being obtained from the areas of pharmacogenetics and operant drug self-administration. 3. The results indicate that reinforcement from alcohol and other drugs is only moderately related to preference for alcohol and other drugs. In addition, neurosensitivity to drugs appears to have little influence on whether that drug will come to serve as a positive reinforcer for any given individual or animal. Indeed, the critical factor appears to be the individual organism's innate propensity to find a particular drug reinforcing. 4. Initial findings also show that genotypic patterns of reinforcement from ethanol appear to correlate highly with patterns of reinforcement from cocaine and opiates. 5. From these findings it is concluded that there exist important genetic determinants of drug reinforced behavior; reinforcement is an important and independent effect of several psychoactive drugs; and drug seeking behaviors maintained by ethanol, cocaine and opiates may have at least some common biological determinants. [References: 53]

Schuckit MA, Hesselbrock V: ALCOHOL DEPENDENCE AND ANXIETY DISORDERS: WHAT IS THE RELATIONSHIP?  American Journal of Psychiatry 1994; 151(12):1723-34.

Summary: OBJECTIVE: In this critical review the authors evaluate the literature regarding the relationship between lifelong DSM-III-R anxiety disorders and alcohol dependence. Many alcohol-dependent individuals demonstrate severe anxiety symptoms in the context of acute or protracted abstinence syndromes, but it is unclear whether these anxiety conditions are independent psychiatric disorders or temporary syndromes likely to disappear on their own. METHODS: Reports since 1975 describing the relationship between alcoholism and anxiety disorders were reviewed to determine whether 1) lifelong anxiety disorders are unusually prevalent among alcohol-dependent individuals, 2) children of alcoholics are more likely to develop anxiety disorders than comparison populations, 3) anxiety syndromes are likely to disappear with abstinence, 4) the rate of alcohol dependence among subjects with lifelong anxiety disorders is higher than normal, 5) there is familial crossover between alcohol dependence and anxiety disorders, and 6) alcoholism is often preceded by anxiety disorders in groups from the general population studied prospectively. RESULTS: The interaction between alcohol use and anxiety disorders is complex. The available data, while imperfect, do not prove a close relationship between life-long anxiety disorders and alcohol dependence. Further, prospective studies of children of alcoholics and individuals from the general population do not indicate a high rate of anxiety disorders preceding alcohol dependence. CONCLUSIONS: The high rates of comorbidity in some studies likely reflect a mixture of true anxiety disorders among alcoholics at a rate equal to or slightly higher than that for the general population, along with temporary, but at times severe, substance-induced anxiety syndromes. [References: 111]

Gianoulakis C, de Waele JP: GENETICS OF ALCOHOLISM: ROLE OF THE ENDOGENOUS OPIOID SYSTEM. Metabolic Brain Disease 1994; 9(2):105-31.

Summary: At the present time alcoholism is recognized as a metabolic disease exhibiting the clinical features of craving for alcohol, loss of control over drinking, tolerance and physical dependence on alcohol, while both epidemiological and experimental studies have demonstrated that genetic factors may be important in determining whether an individual has a high or low vulnerability to develop alcoholism. Evidence also indicates that alcoholism is not characterized by a single gene single allele inheritance. Instead it seems that multiple genes and environmental factors interact to increase or decrease an individual's vulnerability to become an alcoholic. Current research is aimed at investigating whether certain behavioral, physiological and biochemical markers are highly associated with the incidence of alcoholism. Among the biochemical markers currently under investigation is the endogenous opioid system and its implication in mediating the reinforcing effects of ethanol. It is the objective of this manuscript to review current research on: (a) the interactions of ethanol with the endogenous opioid system at the molecular level; (b) the existence of genetically determined differences in the response of the endogenous opioid system to ethanol between subjects at high and low risk for excessive ethanol consumption, as well as between lines of animals showing preference or aversion for ethanol solutions; (c) the decrease of alcohol consumption following pretreatment with opioid antagonists; and (d) the possible use of specific opioid receptor antagonists together with behavioral therapy to modify drinking behavior, to control craving and to prevent relapse. [References: 121]
Grant BF:


Summary: This paper presents national estimates of alcohol consumption and DSM-IV alcohol abuse and dependence in the United States. Fifty-two percent of the adults surveyed were classified as current drinkers and nearly 9.0% met criteria for DSM-IV alcohol abuse or dependence. Greater percentages of males and whites were classified as current drinkers and as alcohol abusers or dependent, compared with females and non-whites, respectively. There is a need for future epidemiological research to collect better data on drinking patterns as an aid to interpreting socio-demographic differentials and to estimate more precisely the association between alcohol consumption and abuse and dependence in multivariate statistical environments. The critical need to examine the unprecedented reversal of the abuse-to-dependence ratio resulting from the application of the DSM-IV classification is emphasized. The role of future longitudinal alcohol epidemiological research in elucidating the initiation and maintenance of consumption patterns and alcohol use disorders is stressed.

Gunning WB, Pattiselanno SE, van der Stelt O, Wiers RW: CHILDREN OF ALCOHOLICS. PREDICTORS FOR PSYCHOPATHOLOGY AND ADDICTION. Acta Paediatrica 1994; Supplement. 404:7-8.

Summary: Children of alcoholics have a higher risk of psychopathology and alcoholism. Therefore, in 1993 the Amsterdam Institute for Addiction Research initiated a study on vulnerability markers and risk factors in children of alcoholics, aimed at identifying predictors for the development of psychopathology and addiction in children of alcoholics. This article provides a summary of the background, rationales and aims of the study. With more specific and sensitive biological vulnerability markers that indicate risk status, more effective preventive interventions might become available. The biochemical part of the study aims at answering the question whether adenylate cyclase is a vulnerability marker for alcoholism. The psychophysiological part is directed at event-related potentials during task performance to clarify the nature of the brain and cognitive functions that may underlie or relate to vulnerability to alcoholism. The third part, the psychological component, aims at possible psychological mechanisms of enhanced risk of addition in children of alcoholics as well as the relationship with childhood psychopathology. [References: 21]

Littleton J, Little H:  CONCEPTS OF ETHANOL DEPENDENCE. Addiction 1994; 89(11):1397-412.

Summary: Alcohol dependence is considered to be divisible into two types (although the divisions between these are indistinct). These are psychological dependence, in which the rewarding effects of alcohol play a primary role, and chemical dependence, in which adaptive changes in the brain initiate punishing effects on withdrawal of alcohol, and suppression of these becomes the primary motive for using the drug. The neurochemical basis for the rewarding effects of alcohol may be the potentiation of GABA at GABAA receptors (causing relaxation) and release of dopamine from mesolimbic neurones (causing euphoria). The adaptive changes which cause the alcohol withdrawal syndrome are not known for certain, but alterations in GABAA receptors, NMDA receptors and voltage-operated calcium channels all have a claim. However, it is distinctly doubtful whether these all contribute to the negatively reinforcing effects of alcohol that are important in chemical dependence, although they may be important in other pathological effects of alcohol abuse. Current research badly needs better communication between basic scientists and clinicians to establish research goals and to improve current models. [References: 75]


Summary: Magnesium (Mg) deficiency occurs frequently in chronic alcoholism and may contribute to the increased incidence of osteoporosis and cardiovascular disease seen in this population. Mg deficiency is primarily due to renal Mg-wasting and is exacerbated by dietary Mg deprivation, gastrointestinal losses with diarrhea or vomiting, as well as concomitant use of drugs such as diuretics and aminoglycosides. Osteoporosis is prevalent in the alcoholic population. Mg deficiency may contribute to increased bone loss by its effects on mineral homeostasis. In Mg depletion, there is often hypocalcemia due to impaired parathyroid hormone (PTH) secretion, as well as renal and skeletal resistance to PTH action. Serum concentrations of 1,25-vitamin D are also low. These changes are seen with even mild degrees of Mg deficiency and may contribute to the metabolic bone disease seen in chronic alcoholics. Hypomagnesemia in alcoholics may also contribute to increased cardiovascular disease by altering platelet function. Mg deficiency has been demonstrated to enhance platelet reactivity. In these studies, Mg was shown to inhibit platelet aggregation against various aggregation agents. Patients with Mg deficiency were shown to have increased platelet aggregation that was normalized with Mg therapy. The antiplatelet effect of Mg may be related to the finding that Mg inhibits the synthesis of thromboxane A2 and 12-hydroxyeicosatetraenoic acid, eicosanoids thought to be involved in platelet aggregation. Mg also inhibits the thrombin-induced Ca2+ influx in platelets, as well as stimulates synthesis of prostaglandin I2, the potent antiaggregatory eicosanoid. Therefore, Mg deficiency may increase platelet aggregation and cause increased hypertension and atherosclerotic cardiovascular disease in alcoholics.

LeMarquand D, Pihl RO, Benkelfat C: SEROTONIN AND ALCOHOL INTAKE, ABUSE, AND DEPENDENCE: CLINICAL EVIDENCE. [REVIEW]. Biological Psychiatry 1994; 36(5):326-37.

Summary: A large body of literature has emerged concerning the role of the neurotransmitter serotonin (5-hydroxytryptamine, or 5-HT) in the regulation of alcohol intake and the development of alcoholism. Despite the wealth of information, the functional significance of this neurotransmitter remains to be fully elucidated. This paper, part one of a two-part review, summarizes the available clinical research along two lines: the effects of alcohol on serotonergic functioning and the effects of pharmacological manipulation of serotonergic functioning on alcohol intake in normal (nonalcohol dependent) and alcohol-dependent individuals. It is concluded that considerable evidence exists to support the notion that some alcoholic individuals may have lowered central serotonin neurotransmission. [References: 160]

Tsai G, Gastfriend DR, Coyle JT: THE GLUTAMATERGIC BASIS OF HUMAN ALCOHOLISM. American Journal of Psychiatry 1995; 152(3):332-40.

Summary: OBJECTIVE: Although alcoholism is one of the most common psychiatric diagnoses, understanding of its pathophysiology remains poor. Accumulating evidence suggests that neurophysiological and pathological effects of ethanol are mediated to a considerable extent through the glutamatergic system. This article reviews the evidence of ethanol's effects on glutamatergic transmission and proposes a glutamatergic basis for alcoholism. METHOD: The information was derived from original research. The authors located more than 100 articles from psychiatry and neuroscience journals that related ethanol to glutamatergic transmission. They critically reviewed the neurobiology of the glutamatergic system in alcoholism and synthesized a unifying glutamatergic theory. RESULTS: Acute effects of ethanol disrupt glutamatergic neurotransmission by inhibiting the response of the N-methyl-D-aspartate (NMDA) receptor. Prolonged inhibition of the NMDA receptor by ethanol results in development of supersensitivity; acute removal of ethanol causes marked augmentation of activity of postsynaptic neurons, such as those in the noradrenergic system, and, in the extreme, glutamate-induced excitotoxicity. Neurobiological effects of alcoholism, such as intoxication, withdrawal seizures, delirium tremens, Wernicke-Korsakoff syndrome, and fetal alcohol syndrome, can be understood as a spectrum of consequences of ethanol's effect on the glutamatergic system. CONCLUSIONS: A host of findings support the hypothesis that the unifying mechanism of action of ethanol in interference with glutamatergic neurotransmission, especially through the NMDA receptor. Alcoholism may be considered another member of the expanding family of glutamate-related neuropsychiatric disorders. These insights should increase understanding of the biologic vulnerabilities leading to ethanol abuse and dependence and aid development of more effective pharmacologic interventions. [References: 78]

Levy MS: THE DISEASE CONTROVERSY AND PSYCHOTHERAPY WITH ALCOHOLICS. Journal of Psychoactive Drugs 1992; 24(3):251-6.

Summary: This article discusses conducting psychotherapy with alcoholics in light of the controversy about whether alcoholism is a disease. The belief that alcoholism is a disease forces many clinicians to offer abstinence from alcohol as the only option for alcoholics who seek treatment. From this perspective, the alcoholic must be helped to accept the idea that he or she has a disease and that to recover from this problem, drinking must stop. Others maintain that alcoholism may not be a disease and view alcoholic drinking as maladaptive behavior. From this vantage point, helping the patient to control or to moderate drinking might be considered. These two distinct paradigms lead to divergent treatment goals, which leaves the clinician in a quandary about how best to treat an individual who experiences a drinking problem. To resolve this dilemma, it is suggested that the clinician who works with alcoholics entertain a multiplicity of perspectives and should not be blinded by any one paradigm. While control of alcohol intake must take place if such patients are to improve their functioning, the author argues that recovery can occur either by abstinence or through moderating drinking. [References: 42]

el-Guebaly N, Staley D, Leckie A, Koensgen S: ADULT CHILDREN OF ALCOHOLICS IN TREATMENT PROGRAMS FOR ANXIETY DISORDERS AND SUBSTANCE ABUSE. Canadian Journal of Psychiatry - Revue Canadienne de Psychiatrie 1992; 37(8):544-8.

Summary: Studies of the first-degree relatives of patients with alcoholism and anxiety disorders have identified a significant overlap of these disorders. Forty percent of the patients in an outpatient anxiety disorder program were adult children of alcoholics (ACOA), a proportion similar to that found in the substance abuse program. The ACOAs in both programs were younger, had higher co-dependency scores and were younger when they had their first psychiatric contact than the controls. The adult children of alcoholics who had anxiety disorders were more likely to be female and their alcoholic parents were less likely to have had psychiatric antecedents to alcoholism. Aside from substance abuse, similarities in sociodemographic variables and the impact of the parents' alcoholism were noted, reinforcing the hypothesis that vulnerabilities to anxiety disorders and alcoholism overlap.

Ziegler PP: MONITORING IMPAIRED PHYSICIANS: A TOOL FOR RELAPSE PREVENTION. Pennsylvania Medicine 1992; 95(10):38-40.

Summary: Physicians experience a broad spectrum of health problems which can disrupt their personal lives and impair their ability to function professionally. Some of these illnesses--such as alcoholism and other drug dependency, and certain psychiatric disorders--are chronic. While treatment usually results in remission of active symptoms, there is a risk of relapse if necessary steps are not followed. Therefore, the key to continued recovery and stable functioning lies in effective relapse prevention.

Wing DM: A FIELD STUDY OF COUPLES RECOVERING FROM ALCOHOLISM. Issues in Mental Health Nursing 1992; 13(4):333-48.

Summary: Effective recovery from alcoholism demands commitment from both partners in a marriage. The focus of this qualitative study was to learn how couples progressed through recovery and how they achieved their goals conjointly. The Model of Recovering Alcoholics' Behavior Stages and Goal Setting was used as the theoretical base. Twenty-eight couples participated in the study. The author used analytic fieldwork to learn if spouses of alcoholics conformed to the same stages as indicated by the model and to learn the interactive effects of alcoholics' and spouses' stages. As a result, the author developed the Model of Alcoholic Spouses' Behavior Stages and Goal Setting. The research has implications for planning nursing care, determining when to intervene individually versus conjointly, and identifying indicators of relapse.


Recent Developments in Alcoholism 1993; 11:413-27. Summary: Neurobiological research over the past decade has greatly expanded our knowledge of alcohol's interaction with the nervous system and promises significant improvement in pharmacological treatment for all phases of alcoholism. Although no new treatment has yet become standard clinical practice, over the next decade benzodiazepine receptor antagonists and inverse agonists should improve treatment of acute alcohol intoxication, adrenergic agents and anticonvulsants should improve treatment of acute alcohol withdrawal, and serotonin uptake blockers and mu opiate receptor antagonists should improve long-term treatment of alcohol dependence. Future clinical research should reduce the current lack of knowledge on pharmacological treatment of alcoholism in special populations such as women, the elderly, and those with concurrent psychiatric diagnoses. [References: 53]


Summary: A sample of 3,572 chemical dependency inpatients aged 25 to 82 years were the subjects of a study to evaluate whether observed reductions in health care costs are associated with successful recovery from alcoholism and other drug dependence, a function of regression to the mean, or ancillary health care during alcoholism/drug abuse treatment. The total number of hospital days were calculated for the year prior to treatment, and one and two years post-treatment. Utilization rates are not significantly different between recovering and relapsed patients prior to treatment; however, the differences between the two groups for the first and second year post-treatment are significant. The recovery patients showed a continued low utilization rate while the relapsed group had considerably higher utilization in both years. Recovery status is an essential factor to consider when determining valid cost-offsets for medical care utilization after alcoholism/drug abuse treatment.

Bohn MJ: ALCOHOLISM Psychiatric Clinics of North America 1993; 16(4):679-92.

Summary: Several medications may help improve treatment of alcoholic patients. Medications that effectively and specifically reverse symptoms of alcohol intoxication or coma currently are lacking. Benzodiazepines remain the most effective medications for the treatment of alcohol withdrawal and for the prevention of withdrawal seizures and delirium, even though the adrenergic agents clonidine or atenolol may hasten resolution of withdrawal symptoms and facilitate outpatient detoxification. Psychosocial rehabilitation of alcoholics may be improved by judicious addition of the alcohol-sensitizing agents disulfiram and carbimide, the serotonergic drugs fluoxetine and buspirone, the opiate antagonist naltrexone, and, for primarily depressed alcoholics, tricyclic antidepressants. As in psychosocial alcohol rehabilitation, patient-treatment matching may improve results of pharmacotherapeutic intervention. [References: 59]

Chappel JN: LONG-TERM RECOVERY FROM ALCOHOLISM. [REVIEW]. Psychiatric Clinics of North America 1993; 16(1):177-87.

Summary: AA has demonstrated success in steadily increasing membership, with no loss of the proportion of those with over 5 years of sobriety. It has been recognized as effective long-term treatment for alcoholism by psychiatrists and psychoanalysts experienced in treatment of the addictions. The triennial membership surveys of AA have shown stability in 1. A 50% dropout rate within the first 3 months of starting AA. Only 41% of those in the first year will remain in the Fellowship for another year. 2. Roughly equal numbers of those with less than 1 year, 1 to 5 years, and over 5 years of sobriety, with an average length of sobriety of about 4 years. 3. Members having a sponsor (85%) and belonging to a home group (88%). 4. Attendance by members of about three meetings a week, regardless of duration of sobriety. 5. Members telling their doctor that they are in AA, but not helping him or her learn about the program. The survey data also indicate that AA is changing in the following ways: 1. The number of women members has increased to more than one third the total membership. 2. An increasing number of young people, under 30 years of age, to more than one fifth the total. 3. A decreasing number of older people, over 50 years of age, to just under one fourth the total. 4. An increasing number of members who were also addicted to other drugs (46%). Psychiatrists can use these data and knowledge of AA to 1. Increase the effectiveness of referrals of alcoholic patients to AA regardless of age, sex, race, or other characteristics. All are welcome and can benefit. 2. Deal with resistance, which occurs when patients begin to make contact with AA. 3. Help alcoholic patients through the difficult first year of sobriety. 4. Encourage their alcoholic patients to use AA as a program for personal growth and development. 5. Helping dually addicted patients use AA's singleness of purpose to facilitate their recovery. 6. Cooperate with alcohol and drug treatment programs in helping patients transfer to AA and work on an effective program of recovery. 7. Work with members of the local AA Treatment Facilities and Cooperation with the Professional Community Committees in helping alcoholic patients enter and use AA. 8. Provide psychiatric treatment for AA members in ways that support and sustain their program of recovery, especially by avoiding dependence-producing medications. [References: 13]

Collins GB: CONTEMPORARY ISSUES IN THE TREATMENT OF ALCOHOL DEPENDENCE. Psychiatric Clinics of North America 1993; 16(1):33-48.

Summary: Alcoholism treatment has certainly come of age since its inception with the founding of Alcoholics Anonymous in 1935. Although AA is a "fellowship" and is not considered "treatment" per se, the growth and proliferation of professional treatment programs has spawned a significant new sector in the health care industry, with a corresponding rise in health care cost. Because the social cost due to the destructiveness of alcoholism is enormous, however, treatment appears to be a cost beneficial investment for society, both in terms of dollars expended and in terms of the lessening of human misery. Inpatient and outpatient programs appear to be effective, but simplistic comparisons are to be avoided because their populations are frequently much different, with patients with poor prognosis indicators showing up more frequently in inpatient settings. Although outpatient treatment is undeniably cheaper initially, appreciable long-term savings may not be realized because of the greater tendency for recidivism in outpatient-treated groups. Taken as a whole, studies of treatment outcome and cost effectiveness support the view that contemporary alcoholism treatment should provide multiple levels of care, with appropriate matching of patients, depending on severity and various demographic factors. This matching may be difficult to realize in actual practice because of the wide variability among alcoholic patients. Although some patient-treatment matching criteria are now in use by insurance carriers and treatment providers, the long-term efficacy of these criteria have not been tested adequately. In the end, it may evolve that the best determinant of assignment to a particular treatment level or modality might best be done by a responsible clinician exercising good judgment based on experience and training. Appropriate legal and financial accountability for this decision should be based on standards of reasonableness, consistent with criteria used in the treatment of other medical and surgical conditions. The alcoholism clinician is performing a valuable service to humanity and to society. Social policies should support this effort by making available appropriate facilities and programs for treatment, and by promoting access through destigmatization and favorable payment and reimbursement systems. [References: 38]

Marron JT: THE TWELVE STEPS. A PATHWAY TO RECOVERY. [REVIEW]. Primary Care; Clinics in Office Practice 1993; 20(1):107-19.

Summary: Alcoholics Anonymous and its 12 Steps and 12 Traditions have arisen out of the experiences of recovery of alcoholics. It offers an important treatment option to the clinician who sees destructive compulsive disease in his or her practice. Despite their nonscientific, nonrational approach, AA and other 12-step programs have evolved to offer a set of attitudes, beliefs, and behaviors that can facilitate change in this group of patients. AA is the forerunner of the others and offers as its most important characteristics an unconditional acceptance of the patient's alcoholism, an unshaken belief in the concept of alcoholism as a disease, and support to foster a healthy dependence in the alcoholic. The recovery of an alcoholic involves a fairly long initial stage in which denial about alcoholism is broken down with slow and halting identity change. This characteristic underscores the primitive level of ego development in the alcoholic and the need for much continuing support, nurturance, and tolerance. Clinicians can be an important part of this support network by working with AA and other 12-step groups to help break down denial in the patient and direct individuals to the appropriate program. By allying themselves with this method and groups, clinicians will be making powerful statements about their beliefs and attitudes toward these destructive illnesses. [References: 15]

Warner ML, Mooney AJ 3d: THE HOSPITAL TREATMENT OF ALCOHOLISM AND DRUG ADDICTION. Primary Care; Clinics in Office Practice 1993; 20(1):95-105.

Summary: Inpatient treatment of alcoholism is an option indicated by certain clinical criteria. The American Society of Addiction Medicine suggests four levels of care, and six assessment dimensions determine which level of care is indicated. An addiction medicine physician can consult with the primary care physician to recommend appropriate placement in difficult cases. Abstinence is a primary goal of treatment; for without abstinence, no other recovery will be possible. The remaining goals of recovery are detoxification, medical evaluation, stabilization of life-threatening emotional issues, education, identification of barriers to recovery, readjustment of behavior toward recovery, and orientation and membership in a self-help group. Successful family contributions can make the difference between success or failure of treatment goals; the role the family plays in recovery is discussed. Treatment for family members is important; the physical, emotional, and spiritual effects on family members can be just as profound on them as they are on the alcoholic. Continuing care maintains the link between the patient and the professional recovery community after discharge and is appropriate for all patients. Extended care allows for structured support of sobriety and often further progress through psychosocial issues identified during the initial treatment phase (i.e., abuse, molestation, unresolved grief). Extended care is indicated for patients requiring further structured assistance in early recovery. A large variety of treatment options are available once the decision has been made to hospitalize the patient. [References: 29]

Chick J: ALCOHOL DEPENDENCE--AN ILLNESS WITH A TREATMENT? Addiction 1993; 88(11):1481-92.

Summary: Unlike some countries, Britain may have experienced a rise rather than a fall in alcohol-related illness during a decade when consumption has not risen. Objections to the "illness concept" may impede our vision and the range of services we develop. It is possible to agree with objectors to the illness concept that a unidimensional view is unhelpful; that explanations are often only attributions; that the construct "illness" is not needed for help to be offered, its use could undermine self-mastery, and its misuse can breach civil rights. Learning can explain much over-drinking. However, the concept need not imply bimodality of drinkers; the syndrome of alcohol dependence has uses and does not imply a cause; physical and mental explanations are not incompatible; genetic and biochemical research has promise. Developments in treatment are still limited, but the mysteries of the free-will dilemma should not prevent us seeing physiological, psychological and social contributants as partners rather than rivals. [References: 82]


Summary: Most problem drinkers do not seek formal treatment, yet some achieve problem resolution without it. This research investigated variables related to help-seeking and to long-term drinking outcomes in a 3 x 2 factorial design, using 126 problem drinkers who varied in their help-seeking history (no assistance, A.A. only, or treatment plus A.A.) and current drinking status (abstinent more than 6 months or engaging in problem drinking). Dependent variables included alcohol-related negative consequences, dependence symptoms, drinking patterns, other drug use, and demographic characteristics. Formal treatment utilization was associated with greater psychosocial dysfunction, especially in interpersonal relationships, and with greater nonprescribed drug use. Alcohol dependence levels were not related to help-seeking, but higher levels were associated with an abstinent drinking status. Abstinent subjects also showed some evidence of greater social stability, but demographic variables, including gender, did not otherwise differentiate the groups. These findings suggest that help-seeking and attainment of abstinence are somewhat independent processes, but that both relate more to the functional consequences of problem drinking than to stable drinker characteristics.

Janssen PA: ADDICTION AND THE POTENTIAL FOR THERAPEUTIC DRUG DEVELOPMENT. [REVIEW]. EXS 1994; 71:361-70. Summary: Therapeutic drug development in alcoholism could be targeted at any of the following: direct antagonism, substitution, treatment of abstinence, enhancement of aversion, modification of biodisposition, or craving. Ritanserin is a potent, centrally acting, highly selective 5-HT1C/2 antagonist which, in addition to having a sleep-regulating and anti-depression/anti-axiety effect, displays a unique pharmacological action in several animal paradigms of substance abuse which assess drug-craving. In fact, the latter pharmacological action was demonstrated after initial clinical observations suggested an effect of ritanserin in the chronic withdrawal phase after detoxification from alcohol in patients. The results of a recent double-blind, placebo-controlled, trial indicated that ritanserin did not induce aversion to drink alcohol in normal volunteers who display social drinking, but are not suffering alcohol dependence. Currently, a full clinical development program of ritanserin in cocaine and alcohol abuse is ongoing. Three major double-blind, placebo-controlled trials in alcohol dependent patients are in progress. Patients of different severity levels, ranging from mild to very severe, are studied. The dosages of ritanserin tested (2.5 mg, 5 mg, and 10 mg o.d.) are known to be well tolerated and safe. Two trials aim for relapse prevention--clinically defined in one, biochemically defined in the other-, and one trial has improved (reduced) drinking behaviour as a therapeutic goal. This program, which involves close to 900 alcohol-dependent patients, is well under way, and is still picking up momentum. [References: 23]


Summary: Alcoholism is a common disorder that tends to be chronic and relapsing. Although there is clear evidence that treatment can be expected to induce a period of remission or at least decreased symptoms, treatment of alcoholism is generally regarded as unsuccessful. Alcoholism should be approached as a chronic medical disorder such as diabetes or arthritis. Complete abstinence is the preferred goal, but "cures" or permanent abstinence from alcohol are rare. In this model, treatment benefits may be measured by length of remission, reduction in alcohol use, improvement in health and enhancement of social functioning. Treatment continues over a period of years, mainly on an outpatient basis with increasing intensity if symptoms recur. Medications that reduce craving for alcohol or diminish the euphoric effects of alcohol would be very helpful in the management of this chronic disorder. Pre-clinical studies have produced evidence for involvement of the endogenous opioid system in the reinforcing effects of alcohol. Recent controlled clinical trials of the opiate receptor antagonist naltrexone suggest that medications of this type may improve the results of treatment for alcoholism. [References: 21]


Summary: Effective treatment of alcoholism requires adopting a psychodynamically informed case-specific approach. Control mastery theory provides a powerful way to understand and treat the alcoholic patient. The theory posits that individuals hold unconscious pathogenic beliefs that contribute to the development and maintenance of alcoholism. The primary therapeutic goal is to create a safe atmosphere that enables patients to disabuse themselves of their maladaptive beliefs and their attendant guilt. In this way, patients become freer to more accurately test reality and thus more effectively pursue normal developmental goals. The treatment of the alcoholic patient progresses through phases, each of which poses different therapeutic challenges. The salient therapeutic tasks addressed in this article are denial, containing affect, relapse prevention, and Alcoholics Anonymous involvement. By understanding the individual's unique pathogenic belief system, the therapist is better equipped to help the patient through the generic phases and tasks of the recovery process.

Miller KJ: THE CO-DEPENDENCY CONCEPT: DOES IT OFFER A SOLUTION FOR THE SPOUSES OF ALCOHOLICS?   Journal of Substance Abuse Treatment 1994; 11(4):339-45.

Summary: The popularity of the co-dependency concept has grown rapidly in the alcoholism treatment field. At the same time, empirical findings gained through scientific research have raised questions concerning the validity of the concept. This paper discusses some of the problems that are created by the disease model of co-dependency and highlights some alternative views that may be more appropriate. It is argued that the field's understanding of the alcoholic/spouse relationship and its ability to help the spouse are limited unless other conceptualizations are seriously considered. [References: 36]


Summary: Current popular and professional conceptions of alcoholism in the United States blend four models that differ in their emphases and implications and contain mutually contradictory beliefs. Elements of moral-volitional, personality and dispositional disease models have been confused with, and mistakenly attributed to, the essentially spiritual views of Alcoholics Anonymous (AA). An original AA model can be distinguished from prior and subsequent beliefs with which it has been added. Clarity regarding the essential elements of an AA understanding of alcoholism is important both for clinicians and for those who would undertake research on AA. [References: 46]

Khantzian EJ, Mack JE:


Journal of Substance Abuse Treatment 1994; 11(2):77-92.

Summary: Alcoholism is associated with tremendous suffering, psychological denial, and physical and emotional debilitation. Much of the suffering that plagues alcoholics is rooted in core problems with self-regulation involving self-governance, feeling life (affects), and self-care. Alcoholics Anonymous is effective because it is a sophisticated group psychology that effectively accesses, corrects, or repairs these core psychological vulnerabilities. The traditions of storytelling, honesty, openness, and willingness to examine ("take inventory") character defects allow people to express themselves who otherwise do not feel or speak and help those who otherwise are deceitful (to self and others) and would deny vulnerability and limitation to openly admit to it. [References: 59]

Mason BJ, Ritvo EC, Morgan RO, Salvato FR, Goldberg G, Welch B, Mantero-Atienza E:

Niemela O:


Scandinavian Journal of Clinical & Laboratory Investigation - Supplement 1993; 213:45-54.

Summary: Alcohol abuse and alcoholism continue to be a major threat to human health. Given their increasing incidence and the detrimental impact on society, it is actually surprising that no objective, specific indicators for the early detection of alcohol-related health problems are available. A diagnostic test for a disease involving excessive alcohol consumption should be extremely specific in order to achieve positive predictive power, and: ideally it should also be very sensitive in order to identify problem drinkers in broad screening programs. The present research indicates that such a test for alcohol abuse may be provided by measurements of covalent chemical addition products (adducts) of acetaldehyde with biologically stable macromolecules. It was recently demonstrated that proteins modified with acetaldehyde are formed in vivo and can induce an antibody response as a result of alcohol consumption. Monoclonal and polyclonal antibodies raised by immunizations against acetaldehyde-modified proteins recognize acetaldehyde adducts irrespective of the nature of the carrier protein. Use of such antibodies in sensitive two-site immunoenzymatic or immunofluorometric assays has indicated that high acetaldehyde adduct concentrations exist in the erythrocytes of alcohol abusers, in healthy volunteers after a bout of drinking, and also in alcohol consuming mothers who subsequently give birth to children with foetal alcohol effects. We have developed the first immunohistochemical techniques for the detection of acetaldehyde adducts in human tissues. The centrilobular region of the liver of alcohol abusers with an early stage of histological tissue damage was found to contain acetaldehyde-modified epitopes, whereas the adducts were more widespread in advanced liver disease. The diagnostic superiority of acetaldehyde adducts as markers of ethanol consumption is due to the fact that they represent true metabolites of ethanol and allow estimations of past alcohol consumption after the ethanol has been eliminated from the body. Investigations into the formation of acetaldehyde adducts in alcohol consumers do not only have diagnostic applications but also help to explain the pathogenesis of alcohol-induced organ damage.

Many types of hypersensitivity and immune responses are brought about by acetaldehyde-modified proteins. In addition, such metabolites of ethanol also aggravate liver disease through disturbed protein function and stimulation of fibrogenesis. [References: 30]

Liberto JG, Oslin DW, Ruskin


Hospital & Community Psychiatry 1992; 43(10):975-84.

Summary: Alcohol abuse and dependence in elderly persons is of growing social concern. The most consistent findings of cross-sectional and longitudinal studies are that the quantity and frequency of alcohol consumption is higher in elderly men than in elderly women, as is the prevalence of alcohol-related problems. Most studies show a decrease with age in consumption and alcohol-related problems among heavy drinkers. Longitudinal studies show no changes in consumption among light drinkers. Elderly persons with lower incomes consume less alcohol than those with higher incomes. Hospitalized and outpatient populations have more problem drinkers, and the elderly alcoholic is at greater risk for medical and psychiatric comorbidity. About one-third to one-half of elderly alcoholics experience the onset of problem drinking in middle or late life. Outcomes seem to be better for those who have late-onset drinking and may be improved for those treated in same-age rather than mixed-age groups. [References: 70]

Goldbloom DS, Naranjo CA, Bremner KE, Hicks LK:


British Journal of Addiction 1992; 87(6):913-9.

Summary: Theory and empirical evidence support a relationship between the eating disorders (anorexia nervosa and bulimia nervosa) and alcoholism. This study examines the co-prevalence and characteristics of these disorders among two populations of adult women: those presenting for treatment of alcoholism and those referred to a specialized eating disorders program. Twenty-two of 73 females (30.1%) with alcohol problems met psychometric cut-off scores for eating disorder, while 25 of the 96 eating disorder females (26.9%) gave psychometric evidence of alcohol dependence. These rates exceed general population norms. While certain clinical and psychometric features distinguish subgroups with both disorders, the basis for co-prevalence and the implications for treatment are unknown.

Mandell W, Eaton WW, Anthony JC, Garrison R:


Alcoholism, Clinical & Experimental Research 1992; 16(4):734-46.

Summary: A review of the many attempts to establish an association between occupations and alcoholism reveals that most do not deal with data about clinically defined alcoholism but instead use data about cirrhosis mortality, self-reported alcohol problems, and frequent and heavy drinking. The present study establishes an association between occupations and diagnoses of Alcohol Dependence Disorder and Alcohol Abuse Disorder, using data from a large population-based household interview study. Statistical adjustment using logistic methods reveals that apparent associations between occupations and alcohol-related disorders previously reported in the literature are due to characteristics of those employed in various occupations. The prevalence of alcohol dependence and abuse in two high risk industries, construction and transportation, is confirmed. More than one in four construction laborers and one in five skilled construction trades workers received a DIS/DSM-III diagnosis related to alcohol abuse. In the transportation industry one in six heavy truck drivers and material movers received an alcohol diagnosis. Analyses of the data from individuals currently employed and not employed in their occupation reveals reduction in risk for those who leave some occupations and increased risk for those who leave other occupations. Evidence is presented that employment in some occupations may be protective for Alcohol Dependence. The findings support the view that occupation may be associated with Alcohol Dependence and Alcohol Abuse independent of demographic variations. Previously proposed explanatory models for associations between occupations and alcohol problems are called into question because they do not take into account the demographic characteristics and employment status of workers. [References: 66]

Agarwal DP, Goedde HW:


Pharmacogenetics 1992; 2(2):48-62.

Summary: The pharmacogenetic differences among individuals in their capacity to metabolize ingested alcohol are possibly responsible for the large inter-individual and inter-ethnic variations observed in the outcome of alcohol use and misuse. Based on results of adoption, twin, and family studies it is now widely accepted that the vulnerability to alcoholism is determined by genetic factors as well as by environment. There is a constant search for biological markers and specific genes which could identify individuals genetically predisposed to alcohol abuse and alcoholism. Numerous 'candidate genes' for alcoholism have been suggested including the alcohol metabolizing enzymes, alcohol dehydrogenase (ADH) and aldehyde dehydrogenase (ALDH). Both ADH and ALDH exhibit genetic heterogeneity. An atypical form of ADH (ADH2), which contains a variant beta 2 subunit instead of the usual beta 1 subunit, differs substantially from the usual form in its kinetic properties and is found more frequently among the Japanese, Chinese and other Mongoloid populations than in Caucasoids and Negroids. A widely prevalent genetic polymorphism has been observed for ALDH; about 50% of Japanese and Chinese livers possess an inactive ALDH (ALDH2 isozyme) whereas none of the Caucasian or Negroid populations show this isozyme abnormality. These metabolic polymorphisms seem to contribute to differences in the in vivo elimination rate of ethanol and acetaldehyde, and may explain differences in alcohol-related behaviour and its disease outcome. Taken together, Orientals who possess an atypical ALDH2 gene are more sensitive to acute responses to alcohol, tend to be discouraged from drinking alcohol, and consequently are at lower risk of developing alcohol-related disorders. However, more work is needed to support these findings. Recent advances in molecular genetics have made it possible to analyze directly the human genome. This may help in a better understanding of the complex genetic and environmental factors in alcohol abuse by providing prospects for identification of gene loci which may be responsible for predisposition to, and protection from, alcoholism. [References: 87]

Krahn D, Kurth C, Demitrack M, Drewnowski A:


Journal of Substance Abuse 1992; 4(4):341-53.

Summary: Patients with bulimia nervosa frequently have problems with alcoholism and other substance abuse. The goal of this study was to assess whether this relationship between eating abnormalities and substance abuse extends to subthreshold levels of dieting and substance use. A self-administered questionnaire assessing dieting and substance use (alcohol, cigarettes, and marijuana) was completed by 1,796 women prior to their freshman year in college. Using a scale derived from DSM-III-R criteria for bulimia nervosa and previous research in this population, subjects were categorized as nondieters, casual, intense, severe, at-risk or bulimic dieters. The relationship between the dieting-severity category and frequency and intensity of alcohol use and frequency of marijuana and cigarette use was assessed. DSM-III-R criteria for bulimia nervosa were met by 1.6% of the women. Only 13.8% of these women were nondieters. Increasing dieting severity was positively associated with increasing prevalence of alcohol, cigarette, and marijuana use and with increasing frequency and intensity of alcohol use. The bulimic and at-risk dieters were similar in their alcohol and drug use. The relationship between eating disorders and alcoholism and other substance abuse noted in clinical populations extends in a continuous, graded manner to subthreshold levels of dieting and substance use behaviors. Dieting-related attitudes and behaviors in young women may be related to increased susceptibility to alcohol and drug abuse.

Shane SR, Flink EB:


Magnesium & Trace Elements 1991; 10(2-4):263-8.

Summary: The earliest description of clinical magnesium deficiency was reported in 1934. In 1954, Flink reported alcoholism as a cause of magnesium deficiency. This has been confirmed by low serum and tissue levels, balance studies, low exchangeable 28Mg and parenteral Mg retention tests. Alcohol causes urinary Mg wastage, but other mechanisms related to alcoholism contribute to the magnesium deficiency including malnutrition, gastrointestinal losses, phosphate deficiency, acidosis and/or alkalosis, vitamin D deficiency and free fatty acidemia associated with alcohol withdrawal. Mg replacement therapy is recommended to prevent some of the serious sequelae of magnesium deficiency. [References: 42]



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