Alcoholism and Problem Drinking

Alcoholism is a word which many people use to mean alcohol dependence (alcohol addiction). Some people are problem drinkers without being dependent on alcohol. If you are alcohol-dependent then detoxification ('detox') can help you to stop drinking.

There are roughly four levels of alcohol drinking - social, heavy, problem and dependent. As a rule, each level increases the risk to your health and safety.

Social drinking

Most people drink some alcohol. However, even a small amount of alcohol can be dangerous if you drive, operate machinery, or take some types of medication.

Heavy (hazardous) drinking

This is drinking above the recommended safe limits, which are:

  • Men should drink no more than 21 units of alcohol per week, no more than four units in any one day, and have at least two alcohol-free days a week.
  • Women should drink no more than 14 units of alcohol per week, no more than three units in any one day, and have at least two alcohol-free days a week.
  • Pregnant women. Advice from the Department of Health states that ... "pregnant women or women trying to conceive should not drink alcohol at all. If they do choose to drink, to minimise the risk to the baby, they should not drink more than 1-2 units of alcohol once or twice a week and should not get drunk".

Where do these recommendations come from?

  • The Department of Health recommends that men should not regularly drink more than 3-4 units of alcohol a day and women should not regularly drink more than 2-3 units a day. 'Regularly' means drinking every day or most days of the week. And if you do drink more heavily than this on any day, allow 48 alcohol-free hours afterwards to let your body recover.
  • The Royal College of Physicians (RCP) advises no more than 21 units per week for men and 14 units per week for women. But also, have 2-3 alcohol-free days a week to allow the liver time to recover after drinking anything but the smallest amount of alcohol. A quote from the RCP... "in addition to quantity, safe alcohol limits must also take into account frequency. There is an increased risk of liver disease for those who drink daily or near daily compared with those who drink periodically or intermittently."
  • The House of Commons Science and Technology Committee advise that people should have at least two alcohol-free days a week.
  • Some would argue that the upper limits of the recommendations are too high. For example, one study found that more than two units a day for men and more than one unit a day for women significantly increases the risk of developing certain cancers.

One unit of alcohol is in about half a pint of beer, or two thirds of a small glass of wine, or one small pub measure of spirits. See separate leaflet called Alcohol and sensible drinking for details.

Why these recommendations? Your liver processes alcohol. It can only cope with so much at a time. Drinking more alcohol than the liver can cope with can damage liver cells and produce toxic by-product chemicals. Drinking above the recommended safe limit is hazardous. That is, it increases your risk of developing diseases such as cirrhosis (liver damage), damage to the pancreas, certain cancers, heart problems, sexual problems, and other conditions. About 1 in 3 men and about 1 in 7 women drink more than the safe limit. In general, the more you drink, the greater the risk.

For example, if a man drinks five units each day (not greatly over the recommended limit) then, on average, he doubles his risk of developing liver disease, raised blood pressure, some cancers, and of having a violent death.

Problem (harmful) drinking

This is where you continue to drink heavily even though you have caused harm, or are causing harm or problems to yourself, family, or society. For example, you may:

  • Have cirrhosis or another alcohol-related condition.
  • Binge drink and get drunk quite often. This may cause you to lose time off work, or behave in an antisocial way when you drink. But note: not everybody with problem drinking binges or gets drunk. Many people with an alcohol-related condition such as cirrhosis drink small amounts frequently but do not get drunk.
  • Spend more money on alcohol than you can afford.
  • Have problems with your relationships or at work because of your drinking.

Many problem drinkers are not dependent on alcohol. They could stop drinking without withdrawal symptoms if they wanted to. But, for one reason or another, they continue to drink heavily.

Alcohol dependence (addiction)

This is a serious situation where drinking alcohol takes a high priority in your life. You drink every day, and often need to drink to prevent unpleasant withdrawal symptoms (see below). In the UK, about 2 in 100 women and about 6 in 100 men are alcohol-dependent.

If you are alcohol-dependent you have a strong desire for alcohol. Sometimes the desire is overwhelming. You have great difficulty in controlling your drinking. In addition, your body becomes used to lots of alcohol. Therefore, you may start to develop withdrawal symptoms 3-8 hours after your last drink as the effect of the alcohol wears off. So, even if you want to stop drinking, it is often difficult because of the withdrawal symptoms. Withdrawal symptoms include: feeling sick, trembling, sweating, craving for alcohol, and just feeling awful. Convulsions occur in a small number of cases.

As a result, you drink alcohol regularly and depend on it to prevent withdrawal symptoms. If you do not have any more alcohol, withdrawal symptoms usually last 5-7 days but a craving for alcohol may persist longer. The severity of dependence can vary. It can develop gradually and become more severe. You may be developing alcohol dependence if you:

  • Often have a strong desire to drink alcohol and need a drink every day.
  • Drink alone often.
  • Need a drink to stop trembling (the shakes).
  • Drink early, or first thing in the morning (to avoid withdrawal symptoms).
  • Spend a lot of your time in activities where alcohol is available. For example, if you spend a lot of time at the social club or pub.
  • Neglect other interests or pleasures because of alcohol drinking.

If you are alcohol-dependent you are usually tolerant to the effect of alcohol. This means that you need more alcohol to notice any effects and to become drunk. This can make things worse, as it tends to make you drink even more.

If you are alcohol-dependent you may get drunk regularly. However, you may not get drunk. You may drink small amounts regularly to keep any withdrawal symptoms away. You may then be able to hide your problem from others. However, you are still at serious risk of developing conditions due to heavy drinking (liver damage, cancers, etc).

Delirium tremens (DTs)

This is a more severe withdrawal reaction after stopping alcohol. It occurs in about 1 in 20 people who have alcohol withdrawal symptoms about 2-3 days after their last drink. Symptoms include: marked tremor (the shakes) and delirium (agitation, confusion, and seeing and hearing things that are not there). Some people have convulsions. Complications can develop such as dehydration and other serious physical problems. It is fatal in some cases.

If you are alcohol-dependent then it is best to cut back gradually and then stop alcohol completely. Do not stop alcohol suddenly if you are alcohol-dependent. Some withdrawal effects can be severe. This is why it is best to cut down gradually and then stop, or see your doctor about a detox - see later in this leaflet. Also, it is best to cut out alcohol completely if you have a condition due to alcohol, such as liver damage. Otherwise, reducing to a safe level of drinking is an option.

If you are trying to cut down, some tips which may help include the following:

  • Consider drinking low-alcohol beers, or at least do not drink strong beers or lagers.
  • Try pacing the rate of drinking. Perhaps alternate soft drinks with alcoholic drinks.
  • Consider cutting back on types of social activity which involve drinking. Perhaps try different social activities where drinking is not involved. Perhaps reduce the number of days in the week where you go out to drink.
  • Resist pressure from people who encourage you to drink more than you want to.

No one can make you stop or cut down drinking. You have to be committed and determined to do this yourself. However, it can be difficult, and one or more of the following may help.

Accepting the problem

Some people deny to themselves that they have a problem. The sort of thoughts that some people deceive themselves with include: "I can cope", "I'm only drinking what my mates drink", "I can stop at any time".

Accepting that you may have a problem, and seeking help where necessary, are often the biggest steps to cutting back on alcohol, or cutting it out completely.

Self-help

Some people are helped by books, websites, leaflets and their own determination. It is thought that about 1 in 3 people who have a problem with alcohol return to sensible drinking, or stop drinking, without any professional help. See the end of this leaflet for a list of resources.

Talking treatments

Some people are helped by counselling and advice from a practice nurse or doctor. Sometimes a referral to a specially trained counsellor may be advised. They can help you to talk through the issues in more detail and help you to plan how to manage your drinking. In some cases, more intensive talking treatments such as cognitive behavioural therapy (CBT), motivational interviewing, or motivational enhanced therapy may be appropriate. For example, CBT helps you to change certain ways that you think, feel and behave, and may help some people with alcohol problems.

Talking treatments are particularly useful for children with alcohol-related problems who are aged between 10 and 17. Children may also be offered family therapy in which other members of their family may be involved in a course of treatment.

Treating other illnesses

Alcohol may seem to be a quick answer to the relief of stress, anxiety, depression, or other mental health problems. However, the effect is short-lived and drinking a lot of alcohol often makes these conditions worse. If you feel that these conditions are the underlying problem then see your doctor. Medication and talking treatments such as CBT often work well for these conditions, and are a much better long-term option than heavy drinking.

Detoxification (detox)

This is an option if you are alcohol-dependent.

Detoxification, or detox, involves taking a short course of a medicine which helps to prevent withdrawal symptoms when you stop drinking alcohol. Benzodiazepine medicines such as chlordiazepoxide or diazepam are used for detox.

Many GPs are happy to prescribe for detox from alcohol. A common plan is to prescribe a high dose of medication for the first day that you stop drinking alcohol. You then gradually reduce the dose over the next 5-7 days. This usually prevents, or greatly reduces, the withdrawal symptoms. You must agree not to drink any alcohol when you are taking the detox medication. Your GP or practice nurse will usually see you regularly during the time of detox. Also, during this time, support from family or friends can be of great help.

Some people are referred to a specialist drug and alcohol unit for detox. This is usually better for those with little home or social support, those with a history of severe withdrawal symptoms, those with physical illness caused by alcohol, and those where previous attempts to stop alcohol have failed. The medicines used to detox in specialist units are much the same as GPs prescribe, apart from clomethiazole which should only be used in hospitals. Hospital units have more staff and expertise for giving support and counselling than GPs have. People with serious alcohol-related problems may be better off being admitted to hospital for detox.

The medication does not make you stop drinking. You need determination to stop. The medication simply helps you to feel better whilst your body readjusts to not having alcohol. Even after the period of detox you may still have some craving for alcohol. So you will still need willpower and coping strategies for when you feel tempted to drink.

  • Vitamins, particularly vitamin B1 (thiamine), are often prescribed if you are alcohol-dependent - especially during detox. This is because many people who are dependent on alcohol do not eat properly and can lack certain vitamins. A lack of vitamin B1 is the most common. A lack of this vitamin can cause serious brain conditions called Wernicke's encephalopathy and Korsakoff's psychosis.
  • Acamprosate and naltrexone are medicines which can help to ease alcohol craving. Either of these may be prescribed to some people after a successful detox to help them stay off alcohol.
  • Disulfiram is another medicine which is sometimes used following a successful detox. When you take disulfiram you get very unpleasant symptoms if you drink any alcohol (such as flushing, vomiting, palpitations and headache). So, in effect, the medicine acts as a deterrent for when you are tempted to drink. It can help some people to stay off alcohol.
  • Lorazepam, olanzapine and haloperidol are all used in the treatment of delirium tremens.
  • Baclofen is a medicine that is reported in some medical studies to help some people to stay off alcohol or to reduce drinking quantity. It may also reduce craving and reduce anxiety in alcohol-dependent people. However, the evidence for the effect of baclofen is conflicting and other studies do not support these reports. More research is needed to clarify whether baclofen is helpful. Note: it is currently not licensed for the treatment of alcohol-related problems.

Many people who successfully detox go back to drinking heavily again at some point. There are various reasons why this may occur. It is thought that you are less likely to go back to drinking heavily if you have counselling, or other support to help you to stay off alcohol. Your doctor, practice nurse, or local drug and alcohol unit may provide ongoing support when you are trying to stay off alcohol. Self-help groups such as Alcoholics Anonymous have also helped many people to stay off alcohol.

If you do go back to heavy drinking, you can always try again to stop or cut down. Some people take several attempts before they stop drinking, or keep within the safe limits, for good.

Original Author:
Dr Tim Kenny
Current Version:
Peer Reviewer:
Dr Beverley Kenny
Last Checked:
19/07/2012
Document ID:
4679 (v45)
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