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.)