Around 17.6 million American adults—one in every 12—abuse alcohol or have an alcohol addiction, according to the National Council on Alcoholism and Drug Dependence.
Half of all Americans have a family member with an alcohol use disorder, and yet many people don’t fully understand alcohol addiction or know whether they or someone they love is addicted.
Let’s take a closer look at alcohol use disorders—abuse, addiction, and dependence—including what these are, how they develop, and how they’re successfully treated.
Alcohol Abuse, Defined
Alcohol abuse is the act of using alcohol in a way that causes problems in your life, such as:
- Relationship problems with friends, family, or co-workers
- Legal problems related to drinking, such as DUI or assault
- Financial troubles stemming from job loss or spending too much money on drinking
- New or worsened physical or mental health problems
- Finding yourself in dangerous or high-risk situations while under the influence
The most common form of alcohol abuse is binge drinking, which is drinking enough in the space of two hours to bring your blood alcohol level up to .08 percent. For men, this is around five drinks, and for women, it's around four drinks.
The Short- and Long-Term Effects of Alcohol Abuse
According to the Centers for Disease Control, around 88,000 Americans lose their lives each year as a result of alcohol abuse. Drunk driving alone causes more than 10,000 deaths annually.
Short-term risks of alcohol abuse include:
- Alcohol poisoning
- Blacking out or losing memories of the time during which you were under the influence
- Alcohol-fueled violence
- Risky sexual encounters
- Sexual assault
- Pregnancy complications
- Injuries and death resulting from alcohol-related drownings, burns, and falls
Long-term health risks of alcohol abuse include:
- High blood pressure
- Heart disease
- Liver disease
- An elevated cancer risk, particularly of the breast, throat, esophagus, mouth, liver, and colon
- Mental health problems like anxiety and depression
- Social problems including relationship troubles, homelessness, lost productivity, and unemployment
- Alcohol addiction and dependence
How Alcohol Abuse Transitions to Addiction
Alcohol addiction is characterized by compulsive alcohol abuse despite negative consequences. Even though the heavy abuse is causing serious problems in your life, you can’t stop, even though you may want to or try to quit.
Addiction develops from brain changes caused by heavy alcohol abuse. Alcohol, like all other psychoactive drugs, acts on the dopamine system in the brain. Dopamine is a neurotransmitter that produces feelings of pleasure when you do enjoyable activities. It’s a key neurotransmitter involved in the learning, motivation, memory, and reward processes in the brain.
The environmental cues that are consistently present when you drink are stored in your memory center. These may include an emotional state like anxiety, a certain place where you always drink, an activity that you do while drinking, or a person you always drink with.
When you encounter these cues, it triggers the conditioned response of wanting a drink. This occurs through classical conditioning, much like Pavlov’s dog learned that a ringing bell meant dinner time. Once the dog’s brain made the ironclad association between the bell and the subsequent food, he salivated every time the bell rang.
The Disease Model of Alcohol Addiction
Alcohol addiction was once regarded as a moral failing or a sign of a flawed personality. While drinking alcohol has been regarded as an acceptable pastime throughout human history, being intoxicated was considered immoral and undesirable.
Prohibition & Youth
Prohibition in the 1920s gave rise to the voice of disenfranchised young people, who changed the public perception of alcohol consumption through popular culture, including books, film, newspapers, and magazines. According to an article published in the Journal of Public Health, by the time Prohibition was repealed in 1933, the stigma previously associated with public intoxication was all but erased. Even women were unashamed to drink in public.
After World War II, the number of people who developed an addiction to alcohol grew considerably, and by 1960, over 200 theories and definitions concerning alcoholism were on the books. One of these was the disease model, which viewed addiction as a disease that can be diagnosed, observed, understood, treated, and prevented.
Addiction Is a Disease
Today, addiction is widely regarded by the medical community as a multidimensional disease of the brain. It’s progressive, chronic, and relapsing. Progressive means that it will get worse over time. Chronic means that it can’t be cured, but it can be sent into remission. Relapsing means that using again after a period of recovery can cause a recurrence of the addiction, once again characterized by brain changes that lead to compulsive use despite negative consequences.
Lifestyle Choices Play a Role in the Disease
Much like other chronic diseases like diabetes and hypertension, addiction has underlying causes, and its development involves a range of choices and lifestyle factors. But once addiction develops, choice is no longer a factor, just as choice is no longer a factor once you develop diabetes or heart disease.
Risk Factors for Alcohol Addiction
Genetics account for roughly half of your risk of developing an addiction.
The other half involves a range of factors, including biological, psychological,
environmental, and sociocultural risk factors.
Addiction almost always has underlying causes. The most common of these include chronic stress, a history of trauma, and mental illness.
Stress is a normal part of life, and it can even be good for us, motivating us to get things done. Some types of stress are enjoyable, such as the kind you experience on a roller coaster ride or during a horror movie.
Normal Stress Levels
When you’re under normal stress, levels of stress hormones like cortisol, norepinephrine, and adrenaline are elevated. These stress hormones produce the body’s stress response, which includes elevated heart rate, blood pressure, and body temperature and increased muscle tension. Under normal circumstances, when the stressor is resolved, stress hormone levels go back to normal.
Chronic & Acute Stress Are Different
Chronic stress is different from every day, acute stress. Chronic stress is always there, humming below the surface day after day. It’s the kind of stress that comes from poverty, living with abuse, or having a dysfunctional home life.
The Devastating Health Effects
Chronic stress has devastating health effects, and it increases your risk of substance abuse and addiction. That’s because many people use drugs or alcohol to cope with the stress and the stressors that cause it. While alcohol may seem to help you relax and forget your troubles at the moment, it almost always makes things worse down the road.
According to a study published in the Annals of the New York Academy of Sciences, chronic stress reduces your ability to control your behaviors and can lead to impulsiveness. This increases your risk of developing an addiction.
A History of Trauma
The link between trauma and addiction is well-established. Trauma, such as sexual or physical abuse, natural disasters, or exposure to violence, affects the brain in important ways, especially when trauma occurs during childhood. Trauma elevates activity in the amygdala, which is responsible for the stress response and feelings of fear and anxiety.
Depression, Anxiety & PTSD
It leaves survivors more susceptible to mental illnesses like depression, anxiety, and post-traumatic stress disorder (PTSD). Trauma leads to the development of unhealthy emotional coping skills, such as suppressing emotions or self-medicating them with drugs or alcohol.
The Symptoms of PTSD
Symptoms of PTSD are common among trauma survivors and include nightmares, insomnia, feelings of deep anger, and disturbing thoughts. Flashbacks are also common and occur due to the memory systems of the brain keeping the memory of the trauma in a short-term memory loop rather than sending it to long-term storage. Flashbacks cause trauma survivors to re-live the traumatic experience repeatedly.
Research shows that people who have a history of trauma often use drugs or alcohol to numb their emotions or forget the traumatic experience. They may drink to avoid nightmares, and cope with insomnia, anger, and flashbacks. For many, heavy substance abuse will lead to addiction.
Mental illnesses like anxiety, depression, eating disorders, and PTSD are major factors for developing an addiction. According to the National Institute on Drug Abuse, more than half of all people who are addicted to drugs or alcohol have a co-occurring mental illness. People with a mental illness are twice as likely as the general population to develop a substance use disorder, and those who are addicted are twice as likely as the general population to also suffer from a mental illness.
Many people with a mental illness self-medicate with drugs or alcohol, but these almost always make the mental illness worse and can even cause the onset of a mental illness that didn’t previously exist. For this reason, it’s often hard to determine which came first—the addiction or the mental illness.
Dependence Is Not the Same Thing as Addiction
Alcohol dependence is the result of changes in the brain’s chemical function in response to heavy alcohol abuse. Initially, alcohol increases the activity of the neurotransmitter GABA, which is responsible for feelings of calm and wellbeing. At the same time, it reduces the activity of the neurotransmitter glutamate, which governs feelings of excitability.
With heavy, chronic alcohol abuse, the brain compensates by reducing the activity of GABA and increasing the activity of glutamate. This leads to tolerance, which means that you need increasingly larger doses of alcohol to get the desired effects. But the more you drink, the more the brain changes.
At some point, neurotransmitter function may shift so that the brain now operates more comfortably when alcohol is present. Then, when you stop drinking, normal neurotransmitter function rebounds. The GABA that was suppressed now floods the brain, and glutamate activity, which was elevated, now drops. This sudden rebounding of neurotransmitter activity causes the onset of physical withdrawal symptoms, which may include seizures and dangerous shifts in heart rate and blood pressure.
Signs & Symptoms of an Alcohol Use Disorder
The Diagnostic and Statistical Manual (5th Edition), or DSM-V, outlines the diagnostic criteria for alcohol abuse, addiction, and dependence, all of which fall under the umbrella of “alcohol use disorder,” or AUD. An AUD is classified as mild, moderate, or severe, depending upon how many of the DSM-V diagnostic criteria you meet.
The criteria cover past-year use. Meeting two or three criteria denotes a mild AUD. Meeting four or five indicates a moderate AUD. A severe AUD is diagnosed when six or more of the criteria apply.
The eleven criteria for AUD are:
- Drinking more alcohol, or for longer periods of time, than you intended
- Wanting or trying to stop drinking but finding you can’t
- Spending a lot of time drinking or recovering from drinking
- Wanting a drink so badly that you can’t focus on anything else
- Neglecting responsibilities at home, work, or school
- Drinking even though it’s causing problems with your relationships
- Losing interest in activities you once enjoyed in favor of drinking
- Finding yourself in dangerous or high-risk situations while under the influence
- Continuing to drink despite new or worsening alcohol-related physical or mental health problems
- Developing a tolerance for alcohol so that more is needed to get the desired effects
- Experiencing withdrawal symptoms when you stop drinking
Other signs of an alcohol use disorder include:
- Withdrawal from friends or family
- Hiding alcohol at home or at work
- Lying to others about the extent of your alcohol use
- Erratic or violent behavior
- Worsened anxiety or depression, or the onset of new symptoms of mental illness
- Denial that you have a problem despite all signs to the contrary
- Becoming defensive or angry when someone tries to talk to you about your alcohol use
The National Institute on Drug Abuse stresses that willpower and good intentions are rarely enough to end an addiction for the long-term. Recovery almost always requires professional help.
How Alcohol Dependence Is Treated
The first step in addiction treatment is medical detox, which involves withholding alcohol so that all traces can leave the body and brain function can begin to return to normal. Detox ends the physical dependence on alcohol.
Medical detox is supervised by medical and mental health professionals. A variety of medications are given as needed to reduce the severity of withdrawal symptoms and prevent or treat dangerous symptoms that can quickly turn fatal.
Symptoms Associated with Alcohol Withdrawal
Alcohol withdrawal symptoms can range in intensity from mild to severe. Not everyone will experience all of the symptoms of withdrawal, which can last anywhere from a few days to a few weeks. How long detox takes depends on a number of factors, including age, state of physical and mental health, and how much alcohol is in the body at the time of detox.
Symptoms of alcohol withdrawal include:
- Cravings for alcohol
- Anxiety or depression
- Irritability and mood swings
- Difficulty concentrating
- Nausea and vomiting
- Insomnia and nightmares
- Hallucinations that can be distinguished from reality
A severe form of alcohol withdrawal known as delirium tremens, or DTs, may occur between 48 and 96 hours after the last drink. These symptoms can be dangerous or life-threatening and include:
- Sudden delirium
- Hallucinations that can’t be distinguished from reality
- Long-lasting, deep sleep
- Agitation or restlessness
- Chest or stomach pain
- Rapid or irregular heartbeat
- High fever
If you have a high risk of DTs, medications will be given during medical detox to prevent the onset of symptoms.
Medications Used During Alcohol Withdrawal
Medications are given as needed during medical detox and include:
- Benzodiazepines, like Valium or Ativan, which reduce anxiety and agitation that commonly occurs during withdrawal. This can be due to elevated levels of glutamate and stress hormones, or it may be due to fear of the prospect of living without alcohol as a form of self-medication.
- Anticonvulsants, which may be used to prevent or treat seizures.
- Acamprosate, which helps to balance the neurotransmitters GABA and glutamate to help reduce cravings.
- Naltrexone, which reduces cravings for alcohol and lessens feelings of intoxication if you drink while on it.
- Zofran, which can help ease nausea.
Complementary Therapies in Alcohol Detox
High-quality treatment programs typically offer a variety of complementary treatment therapies during medical detox, which help reduce symptoms and improve feelings of well-being. Complementary therapies commonly used during detox include:
- Restorative yoga, a combination of controlled breathing and long-held poses that reduce stress and increase feelings of well-being
- Acupuncture, which can reduce the intensity of withdrawal symptoms and help improve the function of the body’s systems
- Nutritional therapy to help identify nutritional deficiencies and develop a healthy eating plan
- Massage therapy to reduce stress and promote feelings of well-being
Developing a Treatment Plan in Detox
Detox only takes care of the physical dependence on alcohol. Treating the addiction is far more complex and requires a variety of therapies and interventions.
During medical detox, you’ll meet with a variety of medical and mental health care professionals for assessments that will include:
- A full medical history
- A nutritional assessment to evaluate your diet and eating habits
- A mental health evaluation to identify any co-occurring mental illnesses like anxiety, depression, or eating disorders
- A psychiatric evaluation to get a better understanding of your current mental health problems in relation to your mental health history
- An evaluation for a history of trauma, such as sexual abuse or rape, being the victim of violence, or a natural disaster survivor.
The information collected during these assessments will help providers place you in an appropriate treatment program and will shape your treatment plan throughout your recovery.
Fostering a Readiness for Change
During medical detox, a critical function of providers is to bring you to a place where you’re ready for a change. This is done through motivational enhancement therapy or MET.
During MET, a therapist opens a dialogue about your substance abuse and prompts self-motivational statements. MET helps you identify your inherent strengths and values and examines how your current thoughts and behaviors align with them. MET is successful in resolving ambivalence toward recovery and increasing engagement in treatment in people who are addicted to alcohol, according to the National Institute on Drug Abuse.
How Alcohol Addiction Is Treated
Addiction is successfully treated by addressing a wide range of needs and issues unique to the individual. In addition to involving underlying factors that led to the substance abuse in the first place, addiction causes a myriad of problems in your life, including relationship and financial problems, job loss, illness or injury, worsened mental health problems, legal troubles, and a lack of self-care. All of these issues must be addressed for a successful recovery.
According to the Substance Abuse and Mental Health Services Administration, a holistic treatment program that addresses issues of body, mind, and spirit offers the best recovery outcomes. A holistic program will include a variety of traditional and complementary therapies that help you:
- Identify unhealthy thought and behavior patterns and replace them with healthier ways of thinking and behaving
- Address underlying issues, including trauma and stress
- Manage symptoms of mental illness
- Develop the skills you need for successful recovery
- Find purpose and meaning in life
- Learn to relax and have fun without alcohol
- Develop hobbies and interests outside of drinking
- Repair damaged relationships
- Restore function to all areas of your life
- Reduce stress
- Improve self-esteem
- Cope with negative emotions and experiences
Therapy takes place in both group and individual settings. Group therapy is highly effective for increasing personal accountability, getting emotional support and working on social and communication skills. Individual therapy focuses on your unique problems and individualized coping strategies.
Traditional Therapies Used in Treatment
Traditional therapies are those that have been shown through research to be effective for treating addiction. Traditional therapies commonly used in treatment programs include:
- Cognitive-behavioral therapy, or CBT, to help you examine your thought and behavior patterns and develop essential coping skills.
- Acceptance and commitment therapy, or ACT, to help you regulate emotions, develop psychological flexibility and learn to think and act in ways that support your personal values.
- Dialectical behavior therapy, or DBT, which helps you develop a tolerance for distress, develop emotional coping skills, and improve interpersonal relationships.
- Family therapy, which helps restore function to the family system.
- Psychoeducational classes that help you better understand addiction and mental illness, including how they’re treated and what recovery requires.
- Life skills classes that help you develop essential life skills, including setting goals, creating routines, and setting personal boundaries.
- Support group participation, which increases personal accountability, provides a high level of support, and promotes healthy relationships.
Not every therapy is right for every individual. The therapies you participate in will depend on your unique needs and issues.
Complementary Therapies Used in Treatment
Complementary therapies are those that have been shown through research to be effective for treating addiction when they’re used along with traditional therapies. Complementary therapies commonly used in treatment programs include:
- Art or Music therapy, which reduce stress, improve emotional regulation, and improve self-awareness and self-esteem.
- Yoga, which promotes physical and mental strength, flexibility, and endurance.
- Meditation, which improves mindfulness, reduces stress, and helps you better respond to external events.
- Equine therapy, which involves working with horses and promotes self-confidence and healthy communication skills.
- Biofeedback, which involves developing strategies for reducing stress immediately during a session monitoring stress response.
- Nature therapy, which increases self-awareness and self-confidence and promotes self-reflection.
Complementary therapies enhance feelings of well-being and foster a greater sense of self-awareness.
Additional Services & Interventions
In addition to traditional and complementary therapies, a variety of services and interventions may be part of your treatment plan. These include:
- Vocational assistance, such as help with resume writing or job searching
- Educational assistance for those who wish to return to school
- Legal assistance to help you navigate the legal system
- Medical care for acute or chronic illnesses
- Psychiatric care for mental health problems requiring medication
Once treatment is complete, an individualized aftercare plan is put in place to help navigate the early weeks and months of solo recovery. The aftercare plan will include components based on individual need, such as:
- Ongoing individual therapy to continue addressing a variety of issues.
- Ongoing mental health care to monitor mental health and medications used to treat them.
- Ongoing family therapy to strengthen relationships and restore trust.
- Participation in a 12-step or other peer support group.
- Time spent in a sober living community to help you develop independence in a supportive environment.
A case manager will oversee the aftercare plan and make changes as needed to reflect changing and emerging needs.
Inpatient vs. Outpatient Addiction Treatment
Although inpatient treatment offers the best possible outcomes for recovery, outpatient treatment can work for some people.
Outpatient treatment involves living at home and continuing to work, attend school, or care for family members while in rehab. Outpatient treatment offers a few benefits over inpatient treatment:
- It’s less expensive.
- It offers the opportunity to put new skills and strategies to work right away in the “real” world.
- It provides a higher level of privacy since there’s no need to explain an extended absence.
Outpatient treatment may work for people who have:
- A safe and stable living environment
- A high level of support at home and in the community
- A high level of intrinsic motivation to recover
- Good physical and mental health aside from the addiction
- Adequate transportation to and from daily rehab sessions
Inpatient treatment involves living at a residential facility while undergoing rehab. The benefits of inpatient treatment include:
- A high level of structure and supervision
- Around-the-clock support from peers and staff
- The opportunity to focus solely on recovery without external stressors getting in the way
- The opportunity to develop healthy communication and coping skills in a supportive environment
- Intensive therapy and time for rest and relaxation
- A calm, nurturing, and healing environment
Inpatient is essential for people who have:
- A co-occurring mental illness like anxiety or depression
- A long history of substance abuse or a severe addiction
- An unsafe or unstable living environment
- Little structure at home
- Little support at home or in the community
The evaluations you undergo in medical detox will help providers place you in the appropriate treatment setting at the level of treatment that’s right for you.
The Principles of Addiction Treatment
The National Institute on Drug Abuse identifies13 principles that guide an effective treatment program. These include acknowledging that:
- Addiction is a complex disease of the brain that affects brain function and thought and behavior patterns.
- No single treatment is right for every individual. Individualized treatment plans are essential for successful outcomes.
- Treatment must address the individual’s multiple needs and issues, including medical and mental health problems; legal, vocational and educational needs; missing life skills; and relationship and social problems.
- Staying in treatment for an adequate period of time is crucial for long-term success.
- Co-occurring mental illnesses must be addressed at the same time as the addiction. Each disorder must be treated in the context of the other.
- Treatment doesn’t need to be voluntary to be effective.
Why People Resist Treatment
According to the National Institute on Alcohol Abuse and Alcoholism, fewer than eight percent of people with an alcohol use disorder get the help they need to enjoy successful , long-term recovery.
Reasons why they say they don’t seek treatment:
- Fear of what other people will think
- Fear of giving up a drinking lifestyle
- Uncertainty about who they are without alcohol
- An inability to afford treatment
- Denial that their problems are that bad
- Ambivalence about recovery
- The high cost of treatment
Making the decision to get help isn’t an easy one and overcoming an alcohol addiction is challenging. But high-quality treatment does more than help you stop using. It helps you find joy, purpose, and meaning in life; develop healthy, mutually beneficial relationships; and gain essential coping skills that will serve you well for the rest of your life.
Treatment works for most people who engage in their treatment plan, and it can help you improve your quality of life and sense of well-being for the long-term.