Alcohol Use Disorder – A General Overview

MISCONCEPTIONS

  1. One major misconception about people with AUD is that they have to drink alcohol every day. This is simply not true: The individual may drink alcohol every day, or not. The amount of alcohol being consumed is just one part of the diagnosis.

  2. The idea of a “Functioning Alcoholic” is also somewhat unclear. Typically this term is used to describe someone who manages to fulfill major responsibilities (such as paying bills, getting to work on time, transporting children to and back from school, etc.) while still maintaining disordered alcohol use. Sometimes people assume that being able to fulfill responsibilities is an assurance that there is no major problem with alcohol. This assumption is not accurate: Being unable to fulfill responsibilities is only one symptom of AUD.1

  3. The consequences from being dependent on alcohol may not always be immediately obvious. There are a wide range of consequences of AUD which can impact every area of life, including physical health (especially internal organs), intrapersonal health (internal feelings), and interpersonal health (relationships) are all areas where the likelihood of experiencing consequences related to AUD is quite high.

  4. A final misconception involves the treatment of AUD and the idea that abstinence is the only acceptable and workable goal for recovery. Clinicians disagree on whether abstinence should be the primary goal of treatment. For many people, abstinence is the best option for recovery; other people choose to pursue moderation of alcohol use.13 There is no single correct path to recovery.13

SYMPTOMS

A person can have mild, moderate, or severe AUD, depending on how many symptoms are present. A person does not need to have all of these symptoms to have AUD, but typically more symptoms means increased severity.1 The following are summarized from the DSM 5.1

  • Loss of control over how much and for how long the person drinks alcohol (for example, intending to only consume two drinks at happy hour and only meaning to stay for one hour, but instead consuming four drinks and staying for two and a half hours)

  • Experiencing a desire to gain control over one’s drinking, without being able to do so. The person may even have tried to cut down or quit alcohol use previously, with little success. It may feel like the alcohol is controlling the person, rather than the person having control over the alcohol.

  • A notable amount of time and energy are spent on acquiring, consuming alcohol, and then recovering from the aftereffects (such as hangovers). This cycle of using alcohol may begin to get in the way of the person’s responsibilities, being able to meet obligations with regard to work, family and friends, one’s children, etc.

  • The person does not change their alcohol use even when major consequences/problems result from too much alcohol use.

  • Strong and irresistible physical or mental craving for alcohol.

  • The person may draw away from or stop doing activities that were once considered important, such as decreasing or stopping activities related to work, friends, or leisure, due to the alcohol use. For example, the individual may isolate and avoid social gatherings or friends s/he once enjoyed.

  • Drinking alcohol in risky situations (such as drinking and driving).

  • Continuing to drink alcohol even though the alcohol causes problems related to a person’s physical health or psychological wellbeing. For example, drinking in spite of the knowledge of severe liver damage.

  • Developing a tolerance to alcohol. Tolerance can be experienced either as needing more alcohol to feel the effects, or reduced effect from drinking the same amount of alcohol

  • Experiencing withdrawal. Sometimes, the person may use more alcohol to feel better from the effects of withdrawal. Withdrawal symptoms can include sweating, difficulty sleeping, tremor, nausea/vomiting, anxiety, hallucinations, and seizures.

CAUSES

As with most mental health issues, there is no simple answer about what causes a person to develop AUD. Alcohol affects everyone differently, and some people are more likely to develop AUD than others.

Genetics plays a prominent role in whether or not someone will become dependent on alcohol: Looking at a person’s family history and the extent to which alcohol addictions are present is the most significant predictor of risk of developing AUD.2

Environment can be part of a person’s risk as well, such as how one’s culture views alcohol use or the amount of peer pressure to drink.1 Another factor is stress level and a person’s ability to cope with that stress; sometimes people who do not have good coping skills turn to alcohol as a means of coping.1

TREATMENT

The goal of treatment may be abstinence, or it may be to achieve moderation or “harm reduction” in alcohol use.13There is some disagreement among professionals here, and different individuals with AUD will have different ideas of which goal fits better.

PSYCHOTHERAPY/BEHAVIORAL HEALTH

Typically treatment for AUD involves talk therapy. There are several different forms of therapy that have been shown to be quite effective with alcohol use disorders as well as with other forms of substance addictions. Some common and effective therapies used with AUD are:

  • Community Reinforcement Approach (CRA): This approach combines different strategies to help the person move forward in readiness to change his/her alcohol use. Typically with CRA, there is an open discussion to learn about the person’s alcohol use for the purpose of building motivation to decrease or stop drinking; “trying on” or “sampling” abstinence for a period of time; an in-depth exploration of “high risk” situations in which the person feels the strongest cravings/urge to drink alcohol; involving a significant other or family member in the recovery process; and reinforcing recovery by exploring other areas of the person’s life (such as leisure and social activities, hobbies) and how these areas may play a role in recovery.5

  • Cognitive Behavioral Therapy (CBT): This approach helps the individual discover how thoughts, feelings, and behaviors have been interacting in a way which support the AUD. For example, maybe a certain pattern of thoughts and behaviors related to feeling anxious often leads a person to drink. The therapist can work with the individual to work on his/her awareness of thoughts, feelings, behaviors, and situations, in order to start changing the pattern to support recovery.15 CBT approaches tend to be quite helpful when the person is ready to make changes.17

  • Motivational Interviewing (MI): An underlying premise of MI is that the person with an addiction has some degree of ambivalence about the behavior; s/he will feel two different ways about the alcohol use. For example, it is common for a person with AUD to recognize the health risks of overusing alcohol, yet doubts his or her own ability to quit drinking, and may delay any attempts to quit drinking. This ambivalence can keep people stuck in the same pattern of alcohol use.16 The focus of MI is to help the person resolve ambivalence so s/he may move forward with a decision about making changes to alcohol use.16

Whatever form of therapy one chooses for help with an alcohol addiction, it is important the therapist has strong empathy for the individual and the individual’s situation. Regardless of the specific treatment approach (such as those listed above), counseling has better outcomes when the client feels the therapist or counselor has good empathy.3 In other words, to boost the likelihood that therapy will be helpful and lead to some success towards recovery, the individual needs to feel like the therapist is truly trying to understand his/her perspective.4

PSYCHOPHARMACOLOGY

There are certain medications which help people manage cravings and increase their ability to stay abstinent or resist using alcohol. These can be quite helpful in combination with talk therapy. Some common medications are:

  • Naltrexone: Reduces the emotional reinforcement of drinking.6

  • Acamprosate: Helps the individual decrease the frequency of drinking alcohol.6
  • Disulfiram (Antabuse): Causes uncomfortable reactions in the body when alcohol is consumed.7

RECOVERY GROUPS

There are various recovery groups which provide structure to people who are interested in working towards change more independently. Some prominent recovery support groups are:

  • Alcoholics Anonymous is perhaps the most well-known of these groups, with chapters in every state, and being a driving force in alcohol addiction recovery for decades. AA utilizes a “step approach,” in which each individual works his/her way through each successive step towards recovery. AA includes an emphasis on spirituality, which works well for some people, and which does not work for others.

  • SMART Recovery is another support group which helps people with all types of addictive behaviors, and uses a “four point” approach to helping individuals build awareness and skills with changing their addiction.8 This group emphasizes reliance on scientifically supported approaches that help with addiction recovery.8

  • Life Ring is a secular recovery support group which encourages abstinence for recovery.9

  • Secular Organizations for Sobriety (SOS) is another secular nonprofit group which also provides guidance for recovery, for religious and nonreligious people.10

  • Al-Anon is a support group for people who have a loved one who struggles with problematic alcohol use.11

STAGES OF CHANGE AND ALCOHOL USE DISORDER

It is very common for people with AUD to pass through various stages of readiness to change their drinking.12 The following points summarize the stages of change, conceptualized by Prochaska and DiClemente, and they are important to keep in mind for anyone suffering with an addiction.12

  • The first stage of change is called Pre-contemplation, which is usually early in the change process. The person in this stage has not started thinking about making any sort of change yet. For example, s/he may be aware of some of the consequences of drinking, yet at this point does not feel a need or desire to cut down or try to stop drinking.

  • The next stage is Contemplation. This is a difficult part of the change process, because it’s where the ambivalence is at its strongest.16 Imagine feeling two ways about something so strongly that it becomes nearly impossible to take action. This is the stage in which the person has awareness about why s/he should quit or cut down on the alcohol use, and yet feels pulled by the factors that have maintained the alcohol use over the years. For example, the contemplative person might think “I need to quit drinking so that I can be a better mom, but how will I manage my stress level without the alcohol?” or “I’m sick of alcohol having so much control over my life, but I’m so scared of withdrawal,” or “If I get one more DUI I’ll lose my license. I have to quit, but what if I lose friends because I won’t drink with them anymore?”

  • The Preparation stage occurs when the individual begins to plan and prepare for change. This stage may involve thinking through the steps actually needed to decrease or quit alcohol. S/he may begin trying on what it will be like to finally have more control over alcohol use, considering different strategies that might be helpful with change.

  • The Action stage occurs when the individual begins taking steps and actively making changes (For example, going to AA meetings, throwing away all the alcohol in the home, driving a different way home to avoid the liquor store, adding new activities to take the place of drinking alcohol).

  • The Maintenance stage involves maintaining sobriety and a long term commitment to recovery from alcohol addiction. Typically the person needs to make lasting lifestyle changes in order to support recovery.

An important point to keep in mind is that people typically relapse before being able to quit or use alcohol in moderation for the long term.14 This is normal, and relapses should not be seen as failures. On the contrary, a relapse represents an important opportunity in which the person can learn more about what may have triggered the relapse and reflect on what to do differently in the future if a similar situation arises. This process of learning and making successive attempts can be helped by speaking with a mental health therapist.

REFERENCES:

  1. American Psychiatric Association (2013). Substance-related and addictive disorders. In Diagnostic and Statistical Manual of Mental Disorders (5th ed.). (pp. 481-589). Washington, DC: Author.

  2. Morse, R.M. Family history and genetics. National Council on Alcoholism and Drug Dependence, Inc. Retrieved from https://ncadd.org/for-parents-overview/family-history-and-genetics

  3. Norcross, J.C., & Wampold, B.E. (2011). Evidence-based therapy relationships: Research conclusions and clinical practice. Psychotherapy, 48(1). 98-102.

  4. Moyers, T.B., & Miller, W.R. (2012). Is low therapist empathy toxic? Psychology of Addictive Behaviors, 27(3). 878-884.

  5. Miller, W.R., Meyers, R.J., & Hiller-Sturmhöfel, S. (1999). The community reinforcement approach. Alcohol Research and Health, 23(2). 116-121.

  6. Garbutt, J.C., West, S.L., Carey, T.S., Lohr, K.N., Crews, F.T. (1999). Pharmacological treatment of alcohol dependence: A review of the evidence. JAMA The Journal of the American Medical Association, 281(14). 1318-1325.

  7. Disulfiram. (2012). Medline Plus. Retrieved from https://www.nlm.nih.gov/medlineplus/druginfo/meds/a682602.html
  8. SMART recovery – Self management for addiction recovery. SMART Recovery: Self-Management and Recovery Training. Retrieved from http://www.smartrecovery.org/

  9. Discover life ring. Life Ring. Retrieved from http://lifering.org/

  10. About S.O.S. Secular Organizations for Sobriety. Retrieved from http://www.sossobriety.org/about-us.html

  11. How Al-Anon/Alateen works for me. Al-Anon Family Groups: Strength and Hope for Families of Problem Drinkers. Retrieved from http://www.al-anon.org/how-al-anon-works-for-me

  12. Diclemente, C.C., Bellino, L.E., Neavins, T.M. (1999). Motivation for Change and Alcoholism Treatment. Alcohol Research and Health, 23(2). 86-92.

  13. Power, E.J., Nishimi, R.Y., Kizer, K.W. (2005). Evidence-based treatment practices for substance use disorders. Workshop Proceedings. Washington, D.C., National Quality Forum.

  14. National Institute on Drug Abuse (2014). Drugs, brains, and behavior: The science of addiction. Retrieved from http://www.drugabuse.gov/publications/drugs-brains-behavior-science-addiction/treatment-recovery

  15. Substance Abuse and Mental Health Services Administration. (2015). Treatments for substance use disorders. Retrieved from http://www.samhsa.gov/treatment/substance-use-disorders

  16. Miller, W.R. & Rollnick, S. (2013). Ambivalence: Change talk and sustain talk. In Motivational Interviewing: Helping People Change (3rd ed). (pp. 157-166). New York, NY: The Guilford Press.

  17. Miller, W.R. & Rollnick, S. (2013). Research evidence and the evolution of motivational interviewing. In Motivational Interviewing: Helping People Change (3rd ed). (pp. 369-386). New York, NY: The Guilford Press.

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