Smoking, Alcohol, and Substance Abuse OVERVIEW OF ALCOHOL-RELATED PROBLEMS Alcohol use is widespread, although the per capita consumption has varied from decade to decade. While U.S. consumption of alcoholic beverages increased after World II, since 1981 it has declined slightly. But even with declines in alcohol use, two of three American adults drink alcoholic beverages. About half of all alcohol consumed in this country is ingested by heavy drinkers, estimated to be between 6.5 and 10 percent of the total population. The extent and frequency with which these individuals drink cause serious health and behavioral problems—disrupting their own lives and that of their family, friends, and employers—and also extracts a heavy societal toll. Alcohol use is involved in: One-half of all murders, accidental deaths, and suicides One-third of all drownings and boating and aviation deaths One-half of all crimes Almost half of all fatal automobile accidents   The health problems associated with alcohol include brain damage, cancer, heart disease, and cirrhosis of the liver.     THE GENETICS OF ALCOHOL Growing evidence supports the theory that heredity predisposes some people toward alcoholism. This research has focused on mutations in the molecular structures of enzymes that metabolize alcohol and may affect the body's ability to excrete alcohol. Researchers have found that the heredity of a large proportion of Asians may prevent them from drinking: These people possess an enzyme ineffective at removing acetaldehyde, the first by-product of alcohol metabolism. When high levels of acetaldehyde build up after consuming a small amount of alcohol, these people suffer discomfort such as skin flushing and rapid pulse. Consequently, the presence of this enzyme, which limits the alcohol that can be consumed before illness ensues, may at least partly explain the low incidence of alcoholism among Asian populations. Studies of individuals with either an alcoholic mother or father or both show that even if they are adopted, they still experience a greater risk of developing alcoholism than the general population. Similarly, offspring of nonalcoholic parents when adopted into families with an alcoholic mother or father are less likely to develop alcoholism than the children of alcoholics. Two types of genetic predispositions have been theorized from research. Male-limited susceptibility. Found primarily in males, this condition is passed on frequently and occurs at an early age. It is associated with criminal tendencies and often requires extensive therapy. Milieu-limited susceptibility. More prevalent, this condition is found in both males and females, is not as severe as male-limited susceptibility, and does not necessarily involve crime. Although inherited, it must be stimulated by environmental factors to manifest itself.     HOW ALCOHOL WORKS IN THE BODY Alcohol is a potent nonprescription drug sold to anyone over the national legal drinking age. This drug is a tranquilizer and a member of the family of sedative-hypnotic drugs. Temperate and occasional users of alcohol who are in normal health do not appear to suffer negative effects from use of alcohol. In moderate doses, alcohol has beneficial effects: relaxation, appetite stimulation, and creation of a mild sense of euphoria. Consumed in substantial amounts, alcohol's toxicity may be because it acts as a foreign substance in the body's metabolism. The short-term expression of this toxicity is felt as a hangover. The long-term toxicity may develop into alcoholism and alcohol-related diseases such as cirrhosis. Unlike carbohydrates, fats, and proteins, which can be manufactured by the body, alcohol is an introduced substance that is not synthesized within the body. It is a food because it supplies a concentrated number of calories, but it is not nourishing and does not supply a significant amount of needed nutrients, vitamins, or minerals—these are empty calories. Most foods are prepared for digestion by the stomach so that their nutrients can be absorbed by the large intestine, but 95 percent of alcohol is absorbed directly through the stomach wall or the walls of the duodenum and the small intestine. Various factors affect the speed of alcohol's absorption into the body. Watery drinks such as beer are absorbed more slowly. Foods (especially fatty foods) delay absorption. Carbonated beverages speed up the emptying of the stomach into the small intestine, where alcohol is absorbed more quickly. The drinker's physical and emotional state (fatigue, stress) and individual body chemistry unpredictably affect absorption. Gender: women have less alcohol dehydrogenase, which breaks down alcohol in the stomach, so more alcohol is absorbed into the bloodstream.   Alcohol moves from the bloodstream into every part of the body that contains water, including major organs like the brain, lungs, kidneys, and heart, and distributes itself equally both inside and outside of cells. Only 5 percent of alcohol is eliminated from the body through the breath, urine, or sweat; the rest is oxidized or broken down in the liver. In the liver: Alcohol is broken down in steps by enzymes until only carbon dioxide and water remain as by-products. Alcohol is processed at the rate of 0.3 ounce of pure ethanol per hour (less than 1 ounce of whiskey), and unprocessed alcohol circulates in the body. (The alcohol from two cocktails—each about 1.5 ounces—ingested before dinner is still present in the body, in a diminished amount, 3 to 4 hours later.)   The liver's fixed rate of alcohol breakdown means that drinking coffee or taking a cold shower does not speed the sobering process. Therefore, giving coffee to a person who is drunk may produce a wide-awake drunk, a chilling prospect if the drunk and friends are deluded into thinking the drinker is sober enough to drive a car. Within moments of ingestion, alcohol reaches the brain where it: Stimulates and agitates, initially producing euphoria Depresses and sedates, producing calmness and tranquility Anesthetizes Induces a hypnotic state and sleep   Alcohol quickly depresses inhibitions and judgment. As inhibitions are released the drinker may feel friendlier, more gregarious, and more expansive. The suggestion to "have a drink and loosen up" is based on the biology of alcohol in the body. Sexual inhibitions may be released, which gives alcohol the reputation as an aphrodisiac; in fact, alcohol impairs sexual function and performance, and eventually blunts desire. Increased consumption may produce Jekyll and Hyde personality changes in drinkers, leading to aggressiveness and cruelty. Radical mood changes (such as bouncing from euphoria to self-pity) are also typical characteristics of intoxication. Alcohol adversely affects motor ability, muscle function, reaction time, eyesight, depth perception, and night vision. Since these are the abilities needed to operate a motor vehicle and since even moderate amounts of alcohol impair these abilities, drivers should never— NEVER—drink and drinkers should not drive. As a drinker continues to drink, alcohol depresses lung and heart function, slowing breathing and circulation. Death can occur if alcohol completely paralyzes breathing. However, this state is seldom reached because the body rejects alcohol by vomiting, or the drinker becomes comatose before he or she can imbibe a fatal dose. Acute alcohol overdose leading to death occurs most often in situations such as bars or college fraternities where individuals may be encouraged to ingest large amounts of alcohol rapidly. A hangover is a combination of physical symptoms. Headache: Blood vessels in the head, dilated by alcohol, painfully stretch as they return to their normal state. Upset stomach: Alcohol irritates the gastric lining, leading to acute gastritis. Dehydration: Alcohol acts as a diuretic, stimulating the kidneys to process and pass more water than is ingested.   Hangover is a withdrawal state. If you medicate this withdrawal with more alcohol, the alcohol will continue to circulate in the blood and will not be completely eliminated. Taking amphetamines (uppers) merely masks hangover symptoms. The best hangover cure is aspirin, liquids, sleep, and time. Bland foods, especially liquids, may also help. The best prevention for a hangover is moderation or abstinence.     PHYSICAL EFFECTS OF ALCOHOL ABUSE Since alcohol so easily permeates every cell and organ of the body, the physical effects of chronic alcohol abuse are wide-ranging and complex. Large doses of alcohol invade the body's fluids and interfere with metabolism in every cell. Alcohol damages the liver, the central nervous system, the gastrointestinal tract, and the heart. Alcoholics who do not quit drinking decrease life expectancy by 10 to 15 years. Alcohol also can impair vision, impair sexual function, slow circulation, cause malnutrition, cause water retention (resulting in weight gain and bloating), lead to pancreatitis and skin disorders (such as middle-age acne), dilate blood vessels near the skin causing "brandy nose," weaken the bones and muscles, and decrease immunity. The liver breaks down alcohol in the body and is therefore the chief site of alcohol damage. Liver damage may occur in three irreversible stages. Fatty Liver. Liver cells are infiltrated with abnormal fatty tissue, enlarging the liver. Alcoholic Hepatitis. Liver cells swell, become inflamed, and die, causing blockage. (Causes between 10 and 30 percent mortality rate.) Cirrhosis. Fibrous scar tissue forms in place of healthy cells, obstructing the flow of blood through the liver. Various functions of the liver deteriorate with often fatal results. (Found in 10 percent of alcoholics.)   A diseased liver: Cannot convert stored glycogen into glucose, thus lowering blood sugar and producing hypoglycemia. Inefficiently detoxifies the bloodstream and inadequately eliminates drugs, alcohol, and dead red blood cells. Cannot manufacture bile (for fat digestion), prothrombin (for blood clotting and bruise prevention), and albumin (for maintaining healthy cells).   Alcohol in the liver also alters the production of digestive enzymes, preventing the absorption of fats and proteins and decreasing the absorption of the vitamins A, D, E, and K. The decreased production of enzymes also causes diarrhea.     THE BRAIN AND CENTRAL NERVOUS SYSTEM Alcohol profoundly disturbs the structure and function of the central nervous system, disrupting the ability to retrieve and consolidate information. Even moderate alcohol consumption affects cognitive abilities, while larger amounts interfere with the oxygen supply to the brain, a possible cause of blackout or temporary amnesia during drunkenness. Alcohol abuse destroys brain cells, producing brain deterioration and atrophy, and whether the organic brain damage and neuropsychological impairment linked to alcohol can be reversed is unknown. Alcohol also alters the brain's production of RNA (a genetic "messenger"), and serotonin, endorphins, and natural opiates whose function may be linked to the addictive process. A neurological disorder called Wernicke-Korsakoff's syndrome results from vitamin B deficiencies produced by alcoholism and the direct action of alcohol on the brain. Symptoms of this condition include amnesia, loss of short-term memory, disorientation, hallucinations, emotional disturbances, double vision, and loss of muscle control. Other effects include mental disorders such as increased aggression, antisocial behavior, depression, and anxiety.   THE DIGESTIVE SYSTEM Large amounts of alcohol may inflame the mouth, esophagus, and stomach, possibly causing cancer in these locations, especially in drinkers who smoke. Alcohol increases the stomach's digestive enzymes, which can irritate the stomach wall, producing heartburn, nausea, gastritis, and ulcers. The stomach of a chronic drinker loses the ability to adequately move food and expel it into the duodenum, leaving some food always in the stomach, causing sluggish digestion and vomiting. Alcohol may also inflame the small and large intestines.   THE HEART Moderate daily drinking may be good for the heart, but for many the risks outweigh the benefits. Even one binge may produce irregular heartbeats, and alcohol abusers experience increased risk of high blood pressure, heart attacks, heart arrhythmia, and heart disease. Alcohol may cause cardiomyopathy (a disease of the heart muscle). Cessation of drinking aids recovery from this condition.     WITHDRAWAL SYMPTOMS Three to 6 days after a heavy drinker (drinking a fifth of liquor a day) completely stops drinking, alcohol is finally gone from the body, and acute and life-threatening effects may occur. Withdrawal phenomena include sleep disorders such as insomnia, visual and auditory hallucinations, disorientation, alcoholic convulsions, epileptic seizures of the grand mal type, and delirium tremens accompanied by acute anxiety and fear, agitation, fast pulse, fever, and extreme perspiration. Consequently, alcoholics who decide to quit drinking should do so under competent medical supervision.     FETAL ALCOHOL SYNDROME DEFINITION Fetal alcohol syndrome (FAS) is a cluster of irreversible birth abnormalities that are the direct result of heavy drinking during pregnancy.   CAUSE Alcohol, like most other drugs, passes easily through the mother's placenta and into the fetal bloodstream. In the fetus, the alcohol depresses the central nervous system and must be metabolized by the immature liver of the fetus, which cannot effectively process this toxic substance. The alcohol stays in the fetus's body for a prolonged time (even after leaving the mother's body) and the unborn child remains intoxicated, possibly suffering withdrawal symptoms after the alcohol is no longer present.   DIAGNOSIS Children born with fetal alcohol syndrome typically are smaller in size, have smaller heads, and suffer deformities of limbs, joints, fingers, and face, as well as heart defects. They may also have cleft palate and poor coordination. In some children, FAS does not appear until adolescence, when they exhibit hyperactivity and learning and perceptual difficulties. These impairments are symptomatic of minimal brain dysfunction (MBD), which affects between 5 and 19 percent of schoolchildren, according to a study by the National Institute of Alcohol Abuse and Alcoholism. Studies of children with FAS who are now teenagers have uncovered new physical problems—ear infections, hearing and vision loss, and dental problems— that were not identified when the children were first studied at a younger age. Only a small percentage of the children born to alcoholic women suffer FAS. The reasons for this are unknown, although it is thought that some children have an increased genetic sensitivity to alcohol. Maternal risk factors for this condition include: Chronic drinking during pregnancy Previous problems with drinking Previous children Being African-American   Some studies have shown that female light-to-moderate drinkers (so-called social drinkers) give birth to babies with subtle alcohol-related neurological and behavioral problems. Although these problems are less severe than those in children of heavy drinkers, these findings indicate that lesser amounts of alcohol can also cause developmental and behavioral abnormalities.   TREATMENT AND PREVENTION Pregnant women should abstain from all alcoholic beverages. Women attempting to conceive should also abstain.     PROFILE OF ALCOHOLISM As noted previously, evidence indicates there may be genetic factors that help determine whether a person will become an alcoholic. A child of an alcoholic has four times the risk of becoming an alcoholic compared with a child of nonalcoholic parents. However, alcoholism is an equal opportunity disease, striking persons of every economic class and race, both genders, and of many ages. Being successful and happy at home or in business is no protection against alcoholism. For many years, alcoholics were viewed as morally defective persons who were the objects of scorn and pity but were not seen as suffering a disease. While the acceptance of this condition as a disease clears the way for understanding, treatment, and recovery, at the same time alcoholics can and must take responsibility for their own recovery. And since alcoholism, like diabetes, is treatable but not curable, recovery from alcoholism lasts a lifetime.     THE BEGINNING STAGES OF ALCOHOLISM Like cancer, alcoholism consists of many diseases, and alcoholics develop alcoholism in different ways. Some alcoholics begin drinking to the point of intoxication from their first drink, immediately behaving in ways destructive to health and relationships. Others suffer a progressive disease, beginning with acceptable social drinking. In the early stages of the condition, the alcoholic comes quickly to depend on the mood-altering qualities of alcohol. Drinks aid mood and are used to perk up, calm down, celebrate, mourn, be sociable, or to withdraw. As the disease progresses, the alcoholic does not need a specific reason to drink, and alcohol is ingested every day, or at prescribed periodic times such as weekends. In the beginning, alcoholics may start a party early by gulping a few quick drinks in the kitchen or they may order doubles when dining out. They feel uncomfortable at social occasions where alcohol is missing. Consumption may be limited and controlled; perhaps to two strong drinks before dinner, moving up to heavier social drinking of three to five a day.     MIDDLE STAGES In the middle stages of alcoholism, the compulsion to begin drinking manifests itself earlier in the day. The drinker prefers alcohol-related activities and friends who drink. An increasing tolerance for alcohol is accompanied by an increasing lack of control, drunkenness, and blackouts, a type of amnesia that allows functioning (such as making dinner or driving) but which blots out memory of the occasion later on. Drinkers in the middle stages of alcoholism may go in and out of a series of blackouts during one drinking episode. At this stage of alcoholism, the first drink of the day sets up a craving for more, and the desire for alcohol overwhelms common sense or what is socially appropriate. (Alcoholics Anonymous members say, "It is the first drink that gets you drunk.") Loss of control while drinking may not inevitably cause drunkenness each time (that is a function of the unpredictability of the drinker's behavior), but sooner or later, that "first drink" will lead to an episode of overindulgence. As the disease progresses, the certainty of getting drunk increases. Drinkers in this stage begin to be secretly ashamed and worried about lack of control. They may try to control their drinking or stop completely, but these attempts often fail. They may switch brands or kinds of alcohol and go from hard liquor to beer. They may seek a "geographic cure," moving to a new city or job in an attempt to cut down, or they may look fruitlessly for some other external formula that will successfully alter their drinking behavior. Eventually the alcoholic exhibits signs of denial, one of the chief psychological symptoms of alcoholism. By refusing to accept the fact of alcoholism, denial allows the drinker to keep drinking while repressing inner conflict. In the midst of the growing problems linked to alcohol consumption, drinkers blame everything except alcohol for their plight. Rationalizations for drinking become manifest, and unhappy relationships, financial difficulties, and work problems are all blamed for the need to drink. What the drinker fails to comprehend and denies strenuously is that the heavy drinking is not the result of these problems but the cause. Although drinkers claim they drink to relieve fatigue, anxiety, and depression, alcohol, in large amounts, exacerbates these feelings. Heavy drinking also brings out feelings of anger, self-loathing, and lack of selfesteem and may produce rages expressed against family members and friends. As drinking progresses, alcoholics experience: Stomach upset Minor hand tremors Increased tolerance for alcohol Morning hangover and shaking hands that require tranquilizers or alcohol to treat.     FINAL STAGES Persons suffering late-stage alcoholism finally grow obsessed with alcohol to the exclusion of almost everything else. They drink despite the pleading of family and the stern advice of doctors. They may begin round-the-clock drinking despite an inability to keep down the first drinks in the morning. Although relationships with family and work may become completely severed, nothing, not even severe health problems, is enough to deter drinking. The late-stage alcoholic suffers a host of fears, including fear of crowds and public places. Constant remorse and guilt is alleviated with more drinking. On top of mental disturbances, debts, legal problems, and homelessness may complicate his or her life. Latestage addiction is characterized by cirrhosis and severe withdrawal symptoms if alcohol is withheld (shakes, delirium tremens, and convulsions). Without hospitalization or residency in a therapeutic community, late-stage alcoholics usually succumb to insanity and death. People suffering alcoholism do not have to "hit bottom" and reach the extreme late stages of alcoholism to decide to get help. Many men and women have recognized their alcohol problems before they lost their jobs or families, or began drinking in the morning, suffered DTs, or had to be hospitalized. For them, the labels "early stage," late stage," "problem drinker," or "alcoholic" were less important than the fact that their growing powerlessness over alcohol was causing them pain.   DIAGNOSIS OF ALCOHOLISM In some cases, the "diagnosis" of alcoholism is made by the courts, as when a judge hands down a drunk driving sentence that includes a requirement to attend Alcoholics Anonymous (AA), or to enter a rehabilitation program. The emergency rooms of hospitals make such diagnoses when a man or woman appears suffering from alcohol poisoning or withdrawal. Some doctors, however, may miss the diagnosis of alcoholism, in part because patients rarely admit to excessive consumption; 50 percent of persons with alcoholism seen by doctors are incorrectly diagnosed. Families may diagnose alcoholism when a family member is hospitalized for the disease or when a spouse leaves because of a drinking problem. However, families may suffer from alcoholism denial in which they completely or partially deny the problem.     INITIAL-STAGE DENIAL Excuses for the drinker's behavior are made to bosses, friends, colleagues, or subordinates. A pattern of lies is woven to cover up for lateness, missed appointments, or irresponsibility. The excuses and lies "enable" the alcoholic to continue drinking and avoid consequences of his or her behavior.     LATE-STAGE DENIAL Family members lose perspective on the problem. The alcoholic promises to stop drinking, then breaks the promise; the alcoholic's spouse makes more demands in an attempt to control the drinking. The spouse of the alcoholic grows suspicious, angry, and despairing. The home environment grows deeply unhappy.   In late-stage denial, the most helpful action for a spouse, family member, or friend is to stop enabling the alcoholic. Alcoholics must admit their problem, see that they are powerless over alcohol and that alcohol has made their lives unmanageable. This realization is difficult if the people around them protect them from the consequences of their behavior. When family members let alcoholics experience these doses of reality, without covering up, the individual with the drinking problem may arrive at a personal moment of truth. Families and friends of alcoholics must do several things to help the alcoholic stop drinking. Abandon wishful thinking that the alcoholic will someday be able to drink safely, recognizing that alcoholism is nearly always progressive. Stop enabling the alcoholic to continue drinking (stop covering up for the drinker's irresponsible behavior). Seek information about alcoholism and its treatment as a disease.     TREATMENT OF ALCOHOLISM Alcoholism enjoys a good recovery rate once the alcoholic stops drinking. Treatment takes many forms because there are many kinds of alcoholics, each with special needs. Treatment sources include hospitals, alcoholism units within hospitals, private clinics designed solely for the care of alcoholics, residential alcoholic rehabilitation facilities, self-help groups such as Alcoholics Anonymous, and private practitioners such as alcoholism counselors, psychologists, psychiatric social workers, and psychiatrists. For a small number of alcoholics, a brief stay of 3 to 10 days in a detoxification center may be necessary. Candidates for detoxification are those who suffer withdrawal symptoms because of the alcohol addiction. At the detox center (hospital unit, nonmedical alcoholism facility, or other institution) the alcoholic's body can clear itself of the alcohol's toxic effects. The patient is cared for with rest, nutritious diet, abstinence from alcohol, and careful medical attention, which may include medication to reduce anxiety and manage withdrawal symptoms and psychiatric evaluation to determine the presence or absence of treatable psychiatric disorders such as depression or anxiety. Treating these, however, will not treat the alcoholism, but not treating them is likely to be associated with failure of the alcoholism treatment. For long-term care, the alcoholic can recover at a rehabilitation center or in the inpatient treatment unit of a hospital. These centers provide alcohol-free environments; continued medical care; group, individual, and family therapy; classes about alcoholism; and regular Alcoholics Anonymous meetings. Alcoholics Anonymous (AA) and its subgroups—Al-Anon for family members of alcoholics and Alateen for teenage children of alcoholics—are self-help organizations that provide experienced advice and support for alcoholics and their families. From 7,000 responses to an informal survey the organization sent to its members in the United States and Canada, 29 percent indicated they had remained sober for more than 5 years, 38 percent for 1 to 5 years, and 33 percent for less than 1 year. Sixty percent of the respondents had sought counseling for alcoholism prior to joining AA. While a scientific analysis of the sobriety success rate for AA is difficult (the organization does not keep membership lists and does not promote itself with sobriety rates), most experts recognize AA as the core of any alcoholic therapy. The "12-step" approach of AA has been widely copied in other selfhelp groups. Outpatient care is also available to patients at rehab centers, allowing individuals to return to work and home while receiving therapy. These centers do not "dry out" alcoholics but provide therapeutic settings in which a bridge back to a normal life can be built. Many alcoholics do not require detox centers or rehab programs but start treatment with a thorough physical exam by a doctor to diagnose possible alcohol-related conditions. The doctor can ease the alcoholic's mind by giving him or her a clean bill of health or by setting up a schedule of continuing care to manage chronic health problems. Early recovery from alcohol is marked by: Occasional thoughts of drinking, especially at times of stress or at cocktail hour. Although the compulsion to drink may be absent, drink desires are a natural reminder of years of drinking and should gradually diminish and need not be alarming. Mood swings. Elation may yield to discouragement and tears. Gradually these wide shifts of mood should moderate.   To combat the early problems of recovery, the alcoholic should: Receive plenty of patience from friends and family. Take adequate rest and a nutritious diet. Join a support group such as AA to share experiences with other people suffering alcoholism.   To help with sobriety, some alcoholics receive Antabuse (disulfiram), a drug that intervenes in the liver's alcohol metabolism, preventing the breakdown of acetaldehyde (an intermediate product of alcohol metabolism). After the administration of Antabuse, even a small sip of alcohol produces acetaldehyde accumulation and nausea, vomiting, severe headache, breathing difficulties, blurred vision, lowered blood pressure, and feelings of impending death. Antabuse use must be consented to by the recovering alcoholic with the clear understanding of its effects. The drug neither alters the alcoholic's mood nor removes urges to drink. Not an instant solution or complete therapy, this drug deters drinking and can play a useful part in treatment if it makes recovering alcoholics feel "protected" from alcohol while learning to stay sober. Antabuse is administered only until the recovering alcoholic feels ready to live without it; it is not taken long term. The narcotic antagonist Naltrexone has recently been approved by the FDA for use in treating alcoholism. It appears to diminish alcohol's pleasurable effects and thus helps keep a "lapse" from becoming a "relapse." Like Antabuse, it is not a cure-all and should be given in the context of relapse prevention training and supportive counseling. Mood-altering drugs such as tranquilizers may occasionally be administered during recovery to quell anxiety. However, one drug habit should not be substituted for another—tranquilizers may be addicting. While some emotional conditions such as manic-depressive psychosis require pharmacological solutions, sobriety should generally be drug-free. This should not prevent individuals who need medications, such as for severe depression, from taking them. While some AA groups discourage even lithium or antidepressants, the Central AA Council recognizes the important role such medications can play for some recovering alcoholics.     LIVING SOBER Quitting drinking is only the first step in recovering from alcoholism. Learning to live without alcohol requires adjustment in attitudes, values, and lifestyles. If serious psychological disturbances have developed because of drinking, psychiatric counseling designed for alcohol abusers may be required. Occupational rehabilitation or vocational guidance also may be necessary. Abstinence is the absence of alcohol or drugs; sobriety is a way of life. Recovery begins where formal treatment leaves off, and this lifelong process never ends. In developing a new way of life, many factors play a part. Recovering alcoholics should avoid people, places, and objects associated with their drinking. After being sober for some time, alcoholics should make new friends and engage in new activities by going to school, returning to work, learning a new hobby, doing volunteer work, or renewing a lost association with their churches or religious groups. Positive addictions should be substituted for alcohol addiction: Walking, jogging, sports, or a regular schedule of exercise promotes well-being and self-esteem and provides a healthy outlet for energy. Research indicates that exercise releases brain chemicals that stimulate a natural high. Even a walk after dinner can act as a tranquilizer that helps alleviate the urge for alcohol.     PREVENTION OF ALCOHOL ABUSE The National Institute on Alcohol Abuse and Alcoholism defines moderate drinking as an average of not more than two drinks per day, and estimates that 15 million adults (15 percent of the drinkers in the United States) consume more than that amount. The 15 percent of men and 3 percent of women who ingest more than four drinks a day risk a serious drinking problem. Anyone, even safe drinkers, can become a statistic when one night's overindulgence leads to a drunk driving incident, a violent family argument, an incapacitating hangover, or some other mishap. Efforts at moderation do not have to be prohibitionist or puritanical. Americans need to view moderation or abstinence as life-enhancing choices rather than negative self-denial. In a statement of goals, the U.S. Department of Health and Humans Services has sought: A freeze in the per capita consumption of alcohol No increase in the proportion of adolescent drinkers A reduction in the cirrhosis death rate and the number of deaths from alcohol-related accidents A reduction in the infants born with fetal alcohol syndrome Increased general public and adolescent awareness of the risks associated with alcohol abuse   Because alcohol use is generally accepted in modern society and alcohol is constantly available (while treatment for alcoholism is not always easy to obtain), these goals present a constant challenge. Most problem drinkers are not presently receiving formal treatment apart from what AA offers. The available treatments are most effective for socially stable, middle-class alcoholics and least effective for the homeless without families. The need to provide increased services of better quality to those with alcoholism is urgent. The major burden of coping with this complex drug problem continues to fall on the individuals and families most directly affected. A further enlightened public policy on alcoholism addressing legal drinking ages, liquor labeling, laws governing drunk drivers, and public education is still necessary. A variety of sources of information about alcoholism is available. The Yellow Pages lists resources under "Alcoholism." Local chapters of the National Council on Alcoholism provide information and referrals. Alcoholics Anonymous and Al-Anon family groups are listed in both the white and the Yellow Pages of the telephone directory. For printed materials, contact the National Clearinghouse of the National Institute on Alcohol Abuse and Alcoholism. (For more information see appendix B, Directory of Health Organizations and Resources.)