Alcohol is of course a legal but controlled drug, similar to the situation with tobacco. Ironically, the misuse of this legal drug (as does the use of tobacco) has costs for individuals and society that far outreach the cost of illegal drugs. The World Health Organisation identifies alcohol (through intoxication, its toxicity, and alcohol dependence), as the third highest risk factor for disease throughout the world. In NZ, alcohol harm costs are estimated at between $1-4 billion each year. Most (81%) New Zealanders consume alcohol, with many (25%) consuming large amounts on a typical session. Maori, Pacific people and young people are all less likely to consume alcohol, but those who do drink are more likely to drink large amounts of alcohol (i.e. binge drink) at each session (MOH 2007).

Other concerning facts are:

• 50%-60% of serious offenders were under the influence of alcohol and/or another drug at the time of offending
• The main cause of alcohol harm is intoxication, resulting in accidents, injuries and violence
• More than one in 20 New Zealanders in the last 12 months were physically assaulted as a result of someone else’s drinking
• Alcohol use is related to 60 diseases including several types of cancer
• Although alcohol problems appear to be widespread, only 1 in 50 have ever received help (alcohol counsellor, GP, AA and others) and only 1 in 125 ever received help from a specialist alcohol counsellor or attended a detoxification programme

Why do we misuse alcohol?

It is apparent that for addictions to develop, be maintained or persevere, and for relapses to occur, there are biological, psychological and social influences occurring. For this reason, in many therapy approaches to reduce or remove the influence of an addiction, each of these three aspects are addressed. This is the case with behavioural addictions that don’t include taking chemicals (e.g. problem gambling, pornography addiction, Internet addiction), as well as the more usual perception of addictions, addiction to chemicals (e.g. alcohol addiction, heroin addiction, methamphetamine addiction, and of course the most common, tobacco addiction).

Biological reasons
This includes the presence of genetic structures that may increase the risk of addiction, and changes to important parts of the brain and its chemicals that occur as a result of using the chemicals, in this case alcohol. Essentially, the brain is wired to be motivated for rewards, and this is present in the most primitive non-human brains. Alongside this is the ability of the brain also to resist the impulse to pursue the reward, especially if we have learned that there will be costs or risks associated with continuing in generating the reward over time. What may make someone more at risk of overuse of alcohol, or to have difficulty stopping once started, is often a mix of inherited genetic factors, and poor development of the ability to resist the impulse to continue. This development to contemplate consequences and resist reward often happens during adolescence, and because this is a period of rapid change, hormones and stress, consequential thinking can come second place to instant gratification. For some adolescents, the ability to resist may be under-developed as they move into later life.

Biologically increased risk
Alcohol acts on a range of neurotransmitters that can heighten rewarding effects or relieve negative effects. These include dopamine, opioid peptides, GABA (short for Gamma-aminobutyric acid), and endocannabinoids. Genetically, some people are born with less dopamine receptors (necessary to complete the reward effect), and may be attracted to the higher levels or strengths of chemicals that ensure that the higher threshold they need to experience reward, is achieved. These same higher levels of chemicals may deter those with normal levels of dopamine receptors, when the reward effect becomes too strong/unpleasant. To further complicate matters, our brain often reduces these receptors to maintain its homeostasis if too high a level of dopamine continues. Others may have a genetic influence that somehow otherwise results in a higher pleasurable outcome for a particular drug such as alcohol and that addiction (rather than binge use) is more likely. Twin studies indicate possibly between 50%-60% of such a person developing an addiction to alcohol being attributable to this inheritance. However, environmental factors in development of addiction remain a high cause. Fortunately, an increased genetic risk for addiction doesn’t mean that this will occur, and the environment we live in can compensate, for example, by adjusting (increase) dopamine receptors to reduce this risk in circumstances as yet not well understood. Others deterred by family alcohol addiction may decide to avoid alcohol misuse, or even use at all, and therefore not place themselves at risk for alcohol addiction.

Alternatively, higher biological risk for addictions may be due to poorly developed frontal lobes that may prevent delayed gratification, and leave people vulnerable to impulsive reactions to drug use. As children and adolescents are developing these parts of the brain, they are particularly vulnerable for drug addictions and for lasting damage to this impulse resisting structure.

Again, things are not simple in the way the brain works, with the brain chemical GABA also being an important player in the development and maintenance of alcohol addiction. GABA stimulation inhibits and is associated with anxiety reduction and euphoria, and is increased with consumption of alcohol and sedative-hypnotic drugs. Although there are probably a number of genes involved and may generalise risk to several drugs of addiction, a gene that codes for a GABA receptor has found to be associated with alcohol dependence in several studies. However, knowledge is at an early stage in this field, with findings that the environment interacting with the gene/s often reduces its/their effect.

Biological prevention
Some people have an inability to process alcohol in their system as well as others due to a genetic enzyme mutation that does not function. Approximately one half of Asians have this different enzyme that shows itself by a flushing effect as the alcohol dilates the capillaries in the face and other places, and alcohol builds up in their system. Although alcohol is itself a poison, acetaldehyde that forms as alcohol is broken down in the liver, is some 30 times as toxic as alcohol, and fortunately doesn’t exist for long, and is quickly broken down into acetic acid (see below). Those with the missing (working) enzyme, retain the toxic acetaldehyde much longer with resulting nausea and the flushing.

Alcohol can therefore have a more intoxicating effect in such a person as it fails to be broken down, result in vomiting, and these effects may deter the drinking of large amounts of alcohol. However, many will address this by the taking beforehand of an acetaldehyde processor such as cysteine can collect and break down acetaldehyde and continue the breakdown process and removal of alcohol from their body.

Psychological reasons
The division into biological and psychological areas are of course artificial as both coexist, interact and are probably each supplying necessary components for an addiction to develop. However, despite the holistic perspective being more correct, separating out the psychological effects can assist with the understanding of why such a powerful addiction can become established with this slower acting, less powerful drug (compared with many illegal drugs). Alcohol is a depressant which slows down the brain and other parts of the central nervous system. Initially inhibitions are reduced and anxieties blunted by alcohol, then impulsive ideas acted upon without restraint of consequential thinking. Excitement is followed by stupor, depending upon amount of alcohol consumed and tolerance levels of the individual. The memory retained of the disinhibited self, and switching off of negative thoughts that persist while sober, can mix with self-promises not to overindulge and embarrass (as may have happened in the past) can result in permission being given to one’s self to use alcohol as a tool to raise one’s mood. For some cultures, including young people, peer group binge drinking may be an acceptable behaviour with normally unacceptable behaviour being excused. Families also may normalise heavy drinking for young people, and early alcohol abuse may affect development of impulse resistant brain mechanisms. For others, biological risk can mix with these learned risk factors, and accelerate alcohol addiction.

For many, the taste of the favourite type of alcohol can gradually give way to the lower financial cost and higher alcohol content to accelerate the achievement of the desired intoxicated state.

As a learned way to reduce stress, escape can become a more immediate solution that learning and experiencing ways to reduce stress in our lives. Unfortunately, escape doesn’t actually address the cause of the stress, and over-indulgence of alcohol may add to negative thoughts when recalling the consequences of the drinking (e.g. embarrassment, missed appointments) , and be a further incentive for escape. In addition to reducing stress, alcohol has the added effect of expected (but often not realised) enhanced sexual anticipation, enhanced feelings of power, assertiveness and aggression. When the obvious attractions of alcohol use outweigh a negative life of daily sobriety, a cycle of addiction can gradually become established.

How is alcohol removed from our bodies?
Alcohol is of course a poison that is capable of killing if taken in large quantities. It is absorbed into the blood system through the stomach and small intestine and then permeates all the organs including the central nervous system, producing the effects described above. Food can slow its absorption, but ultimately it will pass into the blood system. The liver, as a purifying organ for the blood, will break down alcohol at the rate of about one standard drink per hour. This cannot be speeded up, and if the liver is damaged, will work much more slowly (those with long term alcohol abuse may become intoxicated on small amounts of alcohol due to the inability of the liver to break it down).

Alcohol cannot be stored and must be oxidised in order to get rid of it; the vast majority of this occurs in the liver (a lesser amount of oxidation occurs in the stomach, and even lesser amounts for women). A small amount of alcohol is removed from the body by sweating and in breath, however by far the largest removal process is the following chemical process that occurs in the liver:

The acetic acid is broken down to carbon dioxide and water then excreted by the kidneys, and thereby the alcohol is fully broken down and removed from the system. If consumption of alcohol exceeds the capacity of the liver to break it down, alcohol builds up in the blood and continues to circulate and affect the brain, other parts of the central nervous system, and other organs. The post-binge hangover results in headaches from dilated blood vessels in the brain, low blood sugar, and for those with growing dependence, withdrawal symptoms of sweating, tremor, anxiety and increased heart rate. Consumption of more alcohol may re-establish the maladaptive homeostasis that heavy alcohol use has established.

Apart from itself being a poison, it can have additional effects on the body.

Other effects of alcohol on the body
Alcohol unfortunately also has other damaging effects. It increases the amount of fats in the blood system to a level that the liver can’t handle (break down) and these high lipid levels affect the functioning of the liver overall. The liver becomes fatty itself, which can progress to hepatitis, scarring, and ultimately life-threatening cirrhosis.

Alcohol also interferes with the way neurotransmitters work as described above, further causing the body to seek to adapt, with the addictive outcomes described. As with all drugs, continued used can result in the central nervous system adjusting such that higher amount are necessary to gain the required effects.

Also, alcohol may start to be used in conjunction with other drugs with different effects e.g. stimulants. Mixing other depressives (e.g. marijuana) with alcohol can have combined both greater effects than a simple additive effect, while combining stimulants with alcohol can have effects that over-ride the brain’s own compensatory processes, while also reducing the ability to judge what may be a safe level of consumption of either drug. Often poorly understood is the effects of alcohol on many prescribed drugs that may cause potentiated actions, or side effects that result in harm. Probably the highest immediate cost to individuals of alcohol, either over-used or used in conjunction with prescription or illegal drugs, is motor vehicle accidents. Judgement is easily skewed when high levels of alcohol or alcohol and other drugs are consumed. When added to other consequences, such as violence either to or by the user, exposure to risky situations, sexual predation, choking while comatose, which are common as a result of binge drinking or unexpected drug combination effects, harmful use of alcohol can result in high costs, even before the added costs once addiction to alcohol has been established. Other possibilities of harm from alcohol abuse include alcohol overdose, hypoglycaemia, hepatic cancer, and vitamin deficiency disorders, and these risks increase when alcohol is mixed with other drugs, a common occurrence.

Interventions

Reducing risk
Although in the past the approach has focussed largely upon abstinence as a solution to alcohol overuse, a harm reduction approach is now regarded as the best practice. This has the advantage of being able to address a much wider range of alcohol problematic use.

Prevention may be the best approach for those with higher risk for these problems. As stated, young people (both gender) can be at risk for harm both from reduced ability to address impulse as a result of frontal brain development that is not fully developed, and the finding that earlier use/misuse in life of alcohol is associated with higher risk for addiction. For others, genetic risk may exist and become evident from family history of alcohol addiction.

Availability of alcohol alongside cultures of high alcohol use can also be moderated.

For these people, knowledge may allow informed decisions, while alcohol availability through control (laws) can also reduce impulsive decisions to binge. Cultures of high alcohol use can change as awareness grows of the costs, of the influence it has on younger family members, and of processes that can lead to alcohol dependence.

Although experts and laws have some impact on those who misuse alcohol, currently alcohol is readily accessible, while probably less than 10-15% of those being harmed by alcohol seek help from professionals. Communities can be influenced by community leaders and from experiences of consumers describing reality can be an effective way to address cultures of high alcohol use as well as those at risk for alcohol use harm.

For those at risk of alcohol harm, brief interventions can be an effective strategy to influence changes before harm arises, as opposed to the past approach of waiting until people reach their ‘rock bottom’. For influencing cultures where heaving drinking is accepted, enlisting community leaders may accelerate participation in the discussion, and in receiving influential information on the benefits of change, and costs of not changing.

Where individuals are harmfully using alcohol, brief, opportunistic interventions are effective in influencing reflection on their behaviour and motivating help-seeking sooner rather than later.

A project to reduce risk and harm
Counties Manukau District Health Board is in the second year of a project delivered by Abacus to develop the local workforce to reduce hazardous, harmful, and dependent alcohol and other drug use in its region (see summary on this website). Over 1,000 community members have been trained to date in information provision, awareness raising, brief interventions, and referral to specialist services. Consumer representatives have been an important resource in developing these community skills and influencing change of drinking culture through the impact of describing their experiences.

Help for established alcohol harm
Those who may be experiencing moderate to advanced harm (e.g. from addiction to alcohol) from their alcohol consumption can benefit from more individual help. Alcohol problems don’t exist in discrete categories. A continuum of non-harm to serious harm is the best description of the range of alcohol impact. For about 20% of New Zealanders, alcohol is not consumed. This is followed by the majority in NZ who use alcohol in a controlled manner. For uncertain numbers, there may be at-risk use where occasional binges occur, and followed by moderate harm, and finally serious harm where addiction may reside. People can move up and down this continuum, depending upon stress, enlightenment, support, availability and acceptance of drinking behaviour. Those with biological risk may have less control on these movements, while those in environments that accept heavy drinking, may be unaware of growing dependence. Early stages of the alcohol harm continuum may benefit from brief interventions, mid stages may require more counselling, and severe harm may require counselling, support and medical interventions.

Specialist services exist throughout New Zealand that are mostly free of charge to the alcohol user and their family, and for the needs of NZ cultures (contact the Alcohol Drug Helpline for information ph.0800 787 797).

Moderate problems
Counselling approaches can provide insight, motivation, and information, as well as assisting with issues that may have arisen from the alcohol use. Most counsellors use a range of therapies, depending upon the occasion, and include Motivation approaches, Cognitive Behavioural Therapy, and Behavioural therapies (and others) that are generally client centred – the client decides their goals and the counsellor helps to achieve these. Therapies are used in individual and group settings. Most with moderate problems retain some insight as to the costs of their alcohol use, some motivation to change, have not developed health issues from their use, and may have support in their lives. This can mean that they retain resources that can assist them to make relatively quick changes in their lives, and maintain those changes over time. Counselling in the community would be the accepted approach to assist these people to address their alcohol problems, and these services are generally provided free, and usually can make these changes within five or so sessions. Because people differ, session numbers vary widely.

Advanced problems and multiple addictions/issues
As alcohol problems expand, so a person’s resources, health and motivation suffer. For some, their dependence may be on alcohol and other drugs, may have mental health issues such as depression, have physical health problems caused by their alcohol use, may have employment and financial problems, and lost much of their support due to their intoxicated behaviour. In addition, many will have legal problems that may be the motivating or mandated reason for their help seeking. Motivation to address problems ebbs and flows with addictions and this supports the development of opportunistic brief interventions that can strike a note of urgency at that time, and not others.

Detoxification
For many, the withdrawal from alcohol dependence can be risky, especially when severe dependence of alcohol. Detoxification is usually administered over a 5-7 day period. Withdrawal from alcohol use can progress over 3-5 days to delerium tremens (DTs), which involves confusion, hyperactivity, heart fluctuations, and visual hallucinations (with even sounds or smells at times) lasting between hours and weeks. Treatment (e.g. Lidocaine and fluids) must commence immediately as risk of fatality can otherwise be high. Treatment with valium before DTs occur may stop the progression to DTs. Convulsions or seizures similar to epilepsy can also occur, and the valium treatment may also stop progression to these. Anti-seizure medication such as Tegretol and Dilantin is also used.

Other drugs used in detoxification of alcohol dependence are anti-psychotic drugs (e.g. haloperidol), beta blockers such as propranolol to stabilize the heart, and the B1 vitamin thiamin for mild withdrawal (pills) and Wernicke-Korsakoff’s Syndrome (injected).

From the above it is demonstrated that advanced alcohol dependence can produce a very fragile adaptation by the central nervous system in addition to harm to other organs, and readjusting to an alcohol free system can require complex and skilled medical help and monitoring to avoid life-threatening consequences. Even greater care is required where addiction is to alcohol and other drugs, and more complex medical regimens are necessary.

Residential treatment
Where there is little support available, or where control over their behaviour is low, a residential programme can offer an immersion in a recovery programme. Residential programmes offer treatment free of many of the relapse cues of the general community. Experience of sobriety can be time both a stressful time and a time of confronting problems without escape through alcohol, and experiencing positive support from others in a similar situation.

Many residential programmes use a range of group and individual therapies, medical supports, within a strict drug free community. Although relatively few in number, some are free and are publically funded, while others are private and charged for (for more information contact the Alcohol Drug Helpline ph.0800 787 797).

Community treatment
Most treatment or help for alcohol problems occurs in day treatment, or in other words, while the person lives within their community. Even although some with severe alcohol problems must live between counselling sessions in an environment where their control is constantly tested, many either choose to receive community treatment because of commitments (job, family) or are unable to access residential programmes. For most however, their level of dependence on alcohol may not be severe, but either motivation, support or insight has enabled them to access help before becoming more severe. Fortunately, it is no longer necessary to reach ‘rock bottom’ before help is sought, as motivation can ‘raise the rock bottom’ at which a person with alcohol problems determine to seek help. Opportunistic interventions such as empathy and advice from a respected person can be a point at which insight over-rides minimising self explanations and motivation to seek help can succeed.

As before, a range of therapies are used, with support given for social issues that have been damaged by the alcohol behaviour. Individual and group therapies are used, and often clients access both treatment and support groups such as Alcoholics Anonymous (AA; see below).

Medical interventions
Medical interventions are often provided alongside counselling in drugs addiction treatment. Some treatment drugs reduce the surge of dopamine that occurs either from use of the addictive drug such as alcohol, or cues that signal the use (e.g. seeing a bottle of, or advert for, your favourite drink). Research into the use of medications based on another neurotransmitter, GABA, that reduce the effects of the dopamine activity through increasing GABA (GABA agonists), aim to curb urges. Others aim to block opioid receptors that reinforce the positive feelings from alcohol, cause nauseous responses to alcohol consumption (aversive therapy).

Antabuse (disulfiram) prevents the acetaldehyde breakdown process described above with the potent chemical causing immediate nausea and a lasting hangover if alcohol is consumed. It lasts in the system for up to two weeks and no tolerance develops and therefore remains potent. Antabuse increases the level of acetaldehyde by 5-10 times. Its effectiveness of course depends upon the commitment to continue taking the drug, taking into account its severe effect.

Naltrexone is an opioid receptor blocker that aims to decrease cravings. Alcohol also stimulates opioid receptors resulting in a positive experience that reinforces the reward for the alcohol consumption behaviour. Naltrexone assists with relapse prevention through removing this rewarding effect. It is either taken in pill form or in a longer lasting injection.

Acamprosate is used to stabilise the surge of neurotransmitters, although little knowledge exists as to how the drug works on the addiction reward circuit. Topiramate is a derivative of fructose that reduces the effect of the dopaminergic process by reducing its rewarding effects. Although drugs are often used with counselling therapy, an alternative to medications are behavioural (and other) techniques can reduce the power of these cues to stimulate the dopaminergic system (cravings) e.g. aversive imagery, cognitive skills.

Although drugs are often used with counselling therapy, an alternative to medications are behavioural (and other) techniques can reduce the power of these cues to stimulate the dopaminergic system (cravings) e.g. aversive imagery, cognitive skills.

Support groups
AA has been a strong choice, since its establishment in 1935, of those who either have completed counselling/treatment, or choose to use a self-support process over therapists. Many hundreds of AA chapters operate throughout NZ and have their own process, the 12-Step programme that has expanded to a large range of other drug and behavioural addictions. Abstinence rather than harm reduction is its approach, with strong spiritual components. Acknowledgement of the lack of control, acceptance, support from others in the fellowship, appointment of a higher power, and lifelong abstinence have proved to work well for many with alcohol problems who wish to address their own addiction while in the community.

Summary

Alcohol problems, including addiction, remain one of the highest health costs for society. Although focus is often upon the potent illegal drugs such as methamphetamine, the costs to society including violence, overdosing and premature death caused by alcohol far outweighs any other drugs. Fortunately most users of alcohol control their intake of this drug, but problematic use and dependence, along with all of its collateral problems/issues, can develop with little insight and once established, may exist over time without help-seeking due to a range of barriers. Early interventions and strategies that take advantage of the many opportunities that motivate decisions to reduce the harm of alcohol in the community can avoid the high costs and ongoing harm that can arise from reliance upon self motivation and self awareness to seek specialist or AA help.

References

Koob G (2006) The neurobiology of addiction: a hedonic Calvanist view. In Miller W & Carroll K (eds) Rethinking Substance Abuse. NY: Guilford Press.

NZ Drug Foundation (2007) Reducing alcohol and other drug problems in NZ’s criminal justice system: review of the evidence Aug 2007. Well: NZ Drug Foundation.

Childress A (2006) What can human brain imaging tell us about vulnerability to addiction and to relapse? In Miller W & Carroll K (eds) Rethinking Substance Abuse. NY: Guilford Press.

Hasin D, Hatzenbuehler M & Waxman R (2006) Genetics of substance use disorders. In Miller W & Carroll K (eds) Rethinking Substance Abuse. NY: Guilford Press.

Dept of Health (England) and the devolved administrations (2007) Drug Misuse and Dependence: UK Guidelines on Clinical Management. London: Dept of Health (England), the Scottish Government, Welsh Assembly Government and Northern Ireland Executive.

Crumpler A (2006) Understanding addictions. Paradigm. Summer 2006: Illinois Institute for Addiction Recovery.

WHO website http://www.who.int/topics/global_burden_of_disease/en/

Ministry of Health NZ. National Alcohol Action Plan: consultation document July 2008. Wellington: MOH

Ministry of Health (2007) Alcohol use in NZ: Analysis of the 2004 NZ Health Behaviours Survey – alcohol use. Wellington: MOH