Alcohol Use Disorders

Most people have an idea about what alcoholism is, but few are aware of the nuanced differences between alcohol abuse, binge drinking, and alcohol dependence. These references help identify the “style” of alcohol consumption.  There is a tendency to minimize reported symptoms, frequency of use, and/or severity of consequences to avoid the label “alcoholic”.  To describe drinking they use words such as “social, weekend warrior, periodic,  binge use, or intermittent”.  It isn’t always a question of “how much” you drink or “how often”, it is “why” you drink and “what” it does to you.  Regardless of whether it is mild, moderate, or severe, alcohol use left unchecked can quickly snowball beyond your control.

Many people are adverse to labels, especially the label of “alcoholic”.  The DSM-5 has integrated the symptoms previously used to differentiate between alcohol abuse and alcohol dependence into one category – Alcohol Use Disorder with mild, moderate, and severe specifiers.  

Recognizing Alcohol Use Disorders

There are several reasons why people abuse alcohol.  For some, what may have started as one drink to relax in the evening or while attending social events, may eventually turn into a regular habit. Many people find alcohol helps them to be more social and use it as a “social lubricant”.  Some cannot unwind at the end of a day without it.  For others, alcohol is a way to cope with (or self-medicate) depression, anxiety, stress, unhappiness or other feelings that can be numbed through alcohol use.

There is a fine line between alcohol abuse and dependence, which I think made it easier for people to overlook or totally deny problems in the past.  The integration of the two into one category makes it easier to address.   There is no need to split hairs over whether alcohol use is “abuse, binging, or dependence”.  Just ask the following questions:

In the past year, have you?*

1. Had times when you ended up drinking more, or longer, than you intended?
2. More than once wanted to cut down or stop drinking, or tried to, but couldn’t?
3. Spent a lot of time drinking? Or being sick or getting over other aftereffects?
4. Wanted a drink so badly you couldn’t think of anything else?
5. Found that drinking—or being sick from drinking—often interfered with taking care of your home or family? Or caused job troubles? Or school problems?
6. Continued to drink even though it was causing trouble with your family or friends?
7. Given up or cut back on activities that were important or interesting to you or gave you pleasure, in order to drink?
8. More than once gotten into situations while or after drinking that increased your chances of getting hurt (such as driving, swimming, using machinery, walking in a dangerous area, or having unsafe sex)?
9. Continued to drink even though it was making you feel depressed or anxious or adding to another health problem? Or after having had a memory blackout?
10. Had to drink much more than you once did to get the effect you want? Or found that your usual number of drinks had much less effect than before?
11. Found that when the effects of alcohol were wearing off, you had withdrawal symptoms, such as trouble sleeping, shakiness, restlessness, nausea, sweating, a racing heart, or a seizure? Or sensed things that were not there?

The you answer “yes” to 2 or more or more of these questions, you may already have a problem. A healthcare professional can further assess if you have an alcohol use disorder. 

*NIH: National Institute on Alcohol Abuse and Alcoholism. Alcohol Use Disorder: A Comparison Between DSM-IV and DSM-5. (2016, July). Retrieved from https://www.niaaa.nih.gov/publications/brochures-and-fact-sheets/alcohol-use-disorder-comparison-between-dsm

Alcohol Use Designations

So, what’s the difference between “mild, moderate, or severe alcohol use”?  The “style”  of alcohol consumption is often helpful for clarification to the layperson.  The three main styles are commonly referred to as: 

• Binge Drinking
• Alcohol Abuse
• Alcohol Dependence (aka alcoholism)

Binge Drinking

One of the precursors to alcohol abuse that is becoming more and more prevalent (especially on college campuses) is known as binge drinking. Binge drinking is characterized by a person consuming enough alcohol in the span of two hours to bring their blood alcohol level to .08 percent – which is the level that is considered intoxicated according to the law. For men, this means drinking 5 or more drinks, and for women, 4 or more in one sitting. The term “binge” was coined to describe a pattern of excessive drinking followed by a period of no drinking at all.

While binge drinking may not be the same as alcohol abuse, if you binge drink regularly, this is considered hazardous.  Everyone reacts differently to alcohol.  Alcoholic drinks have varying quantities of alcohol content and can cause both short and long term problems for the binge drinker. Combining prescription medications or recreational drugs with alcohol can affect how quickly you reach a high level of intoxication, resulting in dangerous or fatal alcohol-related outcomes. So, while the binge drinker may not have “alcoholism”, the progression from binge drinking to alcohol abuse and then to alcoholism is a short one, and it can happen in short order.

Alcohol Abuse

Alcohol abusers may not drink consistently, but they seem to routinely drink themselves into a quandary by making poor decisions, partaking in risky behavior, or drinking to the point of sickness or even alcohol poisoning. Someone who abuses alcohol is usually a heavy drinker who continues to drink even when it negatively affects them.

There is a fine line between alcohol abuse and dependence – so fine that people who abuse alcohol often become dependent. Having drinks with friends and “over-doing” it on occasion is an alcohol problem, but when you continue to drink despite alcohol-related problems, alcohol has become a problem for you. Some of the problems are listed below:

• Alcohol is affects your job, family and relationships.
• Friends and family raise concerns about your drinking.
• You neglect responsibilities.
• Trouble with law enforcement.
• Drinking while driving.

Alcohol Dependence

Since alcohol is legal and readily available, drinking is often viewed as normal behavior and that is why problems often go unnoticed longer than they should.

Abusing alcohol has serious consequences, however. Dependence on alcohol can contribute to strained relationships, financial trouble and personal insecurity. Without help, you may feel as if you are spiraling out of control.  Loss of control is an earmark for alcohol dependence.

Loss of Control

When someone drinks more alcohol than their body and brain is able to process, this is known as intoxication. It can lead to dangerous and risky behaviors.  It can cause several other problems, including loss of motor control and slurred speech, lowered inhibitions, and an increased sense of bravado, resulting in unintentional injuries, promiscuous behaviors, and even violence.

When you are held hostage by alcohol, you experience loss of control – over drinking and eventually, over your life. This has serious repercussions for people suffering from alcohol dependence. Their own well-being and health are in jeopardy, but so are effects suffered by their families, friends, and even strangers.

Losing control while drinking means that you start drinking and cannot stop. For people who struggle with alcohol dependence, alcohol has such a powerful hold over them that they cannot have just one drink. This leads to intoxication and a host of problems ensue causing irreparable damage to their lives and those people around them. One of the consequences of losing control while drinking is decreased inhibitions and increasingly poor judgment. Regrettably, almost 95% of people sent to treatment for alcohol feel that they have control of the situation and do not need treatment.  This illustrates an extreme lack of judgment and the strong control that alcohol has over the person. Loss of control can also refer to the quantity of alcohol consumed at one sitting. Some statistics show an average of six people die each day from alcohol poisoning.

To those who have not experienced the pain of addiction or a mental health disorder, alcohol dependence (alcoholism) may seem like a general condition that affects everyone in the same way. Alcohol dependence and associated problems are as unique as the individual who is suffering from the disease. It will impact you differently than anyone else.

Treatment 

It is common for individuals to struggle with controlling their drinking at some point in their life. According to the National Institute on Alcohol Abuse and Alcoholism (NIAAA), approximately 17 million adults over the age of 18 have an alcohol use disorder.  

Thankfully, treatment does work. The following information is provided to answer some basic questions about treatment and where to begin seeking it.  If you need further clarification or guidance, please contact me. I’m here to help. 

While I often recommend finding a physician who is certified in addiction medicine (ASAM or CSAM), a good place to start is with your primary care physician.  They can evaluate the severity of drinking patterns, help you make treatment decisions, assess your overall physical health, determine if medications might be appropriate, and recommend an appropriate level of treatment.

ASAM (American Society of Addiction Medicine) divides treatment into five levels.

Level 0 Early Intervention Services

Level 1 Outpatient Services

Level 2 Intensive Outpatient/Partial Hospitalization Services 

Level 3 Residential/Inpatient Services

Level 4 Medically Managed Intensive Inpatient Services

Residential Treatment

Residential (inpatient) Treatment is needed for individuals with more severe or chronic cases of addiction.  Not all residential rehabs are created equal, however, so it is important to make sure you find one suited to meet your needs, not necessarily your “wants”.  

A Residential Treatment Center (RTC) will provide 24-hour care.  Most (but not all) offer clinically managed high-intensity residential services (ASAM 3.5), which typically includes detox, medication management, individual therapy, group therapy, addiction education, couples or family therapy, skills building, aftercare planning, and referrals to support groups. Individuals who are more medically compromised will need to consider residential or inpatient treatment offering ASAM 3.7 or 4.0 levels of care.

Treatment outcomes improve with increased lengths of treatment. A 28-30-45 day treatment stay is a foundation. The individual is learning and practicing new skills to maintain their recovery, however, they are doing so in a contained, regulated environment where they have constant support and oversight.  Aftercare planning is a crucial component for transferring those skills to a less structured living environment. Success in maintaining sobriety hinges on continuity of care and on-going treatment. 

Outpatient Treatment Programs

Outpatient programs are defined by their structure, type of services, and frequency of attendance.  

• A Standard outpatient program is the least intensive.  Typically they meet once or twice a week for a few hours in a group therapy format. They may offer one-to-one counseling with a counselor or licensed therapist. There is little or no medical supervision.
• An Intensive Outpatient Programs (IOP) is just that – more intensive. They meet typically between 9-20 hours per week. The treatment is composed of group counseling, individual counseling, drug testing, family groups, case management, and support group meetings. This is the typically the level of care recommended following discharge from a residential program, but it is also strongly recommended for those seeking treatment that may not need a residential program.
• Partial Hospitalization Programs (PHP) are also known as “day treatment” programs. They may offer treatment up to seven days a week for 3-8 hours a day. Usually, they are offered in hospital or clinical settings.  The services typically include medical and psychiatric care, medication management, group therapy, family therapy, recreational activities, and social services. 

Medication

I know what you’re thinking.  “Why would I want to trade alcohol for another drug?”  Medicated Assisted Treatment (MAT) is recommended in combination with therapy and/or counseling.  According to SAMHSA, research finds it effective for the treatment of substance use disorders.  Not everyone requires medication, but for some it increases their chances for survival and helps them stay in treatment longer. 

Medications approved by the FDA for alcohol use disorders include naltrexone, acamprosate, and disulfiram. Your physician can assess if any of these medications should be part of an appropriate course of treatment for you. While medication can be used alone, I believe treatment of any substance use disorder is most effective when it is combined with other treatment modalities. 

Individual Therapy

Seeing a therapist who is experienced in the treatment of alcohol and other drug use disorders is a valuable resource to explore and identify underlying causes, or the “why” of substance use. They can provide a safe, non-judgmental space to talk about your substance use and any related issues.  

• CBT (cognitive behavioral therapy) is typically used will help you identify relapse cues and manage the cravings and stress that call you to use.  
• Motivational Enhancement strategies are used to help strengthen motivation to change alcohol and other drug use behaviors.  Examining the pros and cons, identifying ambivalence, developing coping skills, identifying successes, and increasing confidence will create faith that the process is working. Having faith in the treatment instills hope for the future and improves motivation to stay the course in the present.
• Marital or Family Counseling can play a very important role in the success of substance use treatment. Interpersonal relationships are often damaged during the course of alcohol or drug use. Often, the spouse, partner, or children need education about substance use to better understand what you are experiencing. Relationships need repair, trust needs to be earned, and family support increases the potential for long term recovery.
• Brief Interventions by a psychotherapist are also beneficial. A supportive, non-judgmental therapist will establish a rapport of trust. Familiarity with your background enables the therapist to objectively identify behaviors that are potential risks for relapse. The therapist’s feedback and direction can help you make healthier choices.

Social Support Groups

Alcoholics Anonymous (AA) and all of the other 12-step groups provide vital peer support. Finding new “like minded” friends who are on the same journey can be very reassuring that you are not alone.  While often confused with a purely religious philosophy, the 12-steps are merely suggestions and provide a behavioral road map for a life free from the ravages of alcohol.  With some variations, the 12 underlying principles to the 12-steps are: 

1. Honesty
2. Hope
3. Faith
4. Courage
5. Integrity
6. Willingness
7. Humility
8. Brotherly love
9. Discipline
10. Perseverance
11. Spirituality
12. Service

SMART Recovery is an abstinence-based program for those with addictive problems. Their approach utilizes a 4-Point Program to effect behavioral change. The 4-Points are: 

1. 1. Building and maintaining motivation to change, 
   2. Coping with urges to use, 
   3. Managing thoughts, feelings and behaviors in an effective way without addictive behaviors,
   4. Living a balanced, positive, and healthy life.

Refuge Recovery is grounded and Buddhist beliefs. They believe the application of Buddhist  teachings can relieve all suffering, including addiction. Refuge Recovery believes the recovery process begins when abstinence begins. They identify 4 Truths and an eight-fold path to recovery.

The Four truths are: 

1. 1. Addiction creates suffering, 
   2. The cause of addiction is repetitive craving, 
   3. Recovery is possible, and 
   4. The path to recovery is available.

The eight factors are not meant to be done in any particular order, but all are to be developed at the same time and maintained throughout the course of life. 

Eight-fold factors: 

1. Understanding
2. Intention
3. Communication/Community 
4. Action
5. Livelihood/Service 
6. Effort
7. Mindfulness/Meditations
8. Concentration/Meditation

Alcohol and drug addiction are hard to unravel.  I am here to help, if you are interested.