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  » Alcoholism and treatment  »  A Widespread Problem

A Widespread Problem

For most people who drink, alcohol is a pleasant accompaniment to social activities. Moderate alcohol use·up to two drinks per day for men and one drink per day for women and older people·is not harmful for most adults. (A standard drink is one 12-ounce bottle or can of either beer or wine cooler, one 5-ounce glass of wine, or 1.5 ounces of 80-proof distilled spirits.) Nonetheless, a large number of people get into serious trouble because of their drinking. Currently, nearly 14 million Americans·1 in every 13 adults·abuse alcohol or are alcoholic. Several million more adults engage in risky drinking that could lead to alcohol problems. These patterns include binge drinking and heavy drinking on a regular basis. In addition, 53 percent of men and women in the United States report that one or more of their close relatives have a drinking problem.

The consequences of alcohol misuse are serious·in many cases, life threatening. Heavy drinking can increase the risk for certain cancers, especially those of the liver, esophagus, throat, and larynx (voice box). Heavy drinking can also cause liver cirrhosis, immune system problems, brain damage, and harm to the fetus during pregnancy. In addition, drinking increases the risk of death from automobile crashes as well as recreational and on-the-job injuries. Furthermore, both homicides and suicides are more likely to be committed by persons who have been drinking. In purely economic terms, alcohol-related problems cost society approximately $185 billion per year. In human terms, the costs cannot be calculated.

Sobering Facts

  • Alcohol accounts for 3 in every 100 cancer deaths in the UK each year.
  • The NHS spends over ?164 million a year on treating alcohol-related conditions.
  • Just under 60% of adults believe that consistently drinking too much is sufficient grounds for divorce.
  • About 900,000 children (aged 5-11) in England have had an alcoholic drink in the last week.
  • In England and Wales, the cost of absenteeism at work, due to excessive drinking, was estimated at ?1,100 million in 1992 - it is estimated that between 9 and 15 million working days are lost annually through this condition.
  • Current estimates suggest 28,000 to 33,000 deaths a year are alcohol-related.

ETHYL ALCOHOL (Ethanol): This is the main constituent of all kind of alcoholic beverages and is generally obtained by fermentation of sugar by yeast. The alcohol is separated by simple distillation. It is a colourless, volatile and inflammable liquid. Neutral spirit contains 90-95% alcohol by volume. Wines containing more than 16% of alcohol are prepared by fortifying by the addition of neutral spirit. The alcohol content of various beverages varies between 4-55% by volume. Stronger preparations are called spirits.

Pharmacological actions: Local actions depend on the concentration of alcohol and the tissue to which it is applied. Because it evaporates quickly from the skin, it has a cooling and refreshing effect and is used for reducing the temperature in fevers. Eau-de-cologne and aftershave lotion are other examples of (cosmetic) preparations used for their cooling effect. In concentrations of 40-50% it has a rubifacient and mild irritant action. Higher concentrations denature proteins by partial precipitation and dehydration; in such concentrations it acts as an astringent, a germicidal and an irritant. Concentrated alcohol, if injected, produces tissue destruction. Alcohol in a concentration of 70% by weight acts as an antiseptic; the action is seen only against vegetative forms of organisms; spores are resistant.

Gastrointestinal tract: Taken orally, if gives a local feeling of warmth and increases the salivary secretion probably by reflex action. It has an irritant action on the gastric mucous membrane and enjoys reputation as an appetizer; 50 ml. Of 7-10% alcohol increases the gastric secretion, probably by releasing histamine and gastrin from the antrum of the stomach, in addition to its psychic and local irritant effects. Concentrations above 15% inhibit both motility and secretion and this effect may persist for many hours. Higher concentrations produce marked irritation of the mucous membrane and may precipitate gastritis, giving rise to nausea, vomiting and other symptoms. Concentrations above 20% reduce the enzymatic activity of the gastric and the intestinal juices. Many chronic alcoholics suffer from gastritis and achlorhydria. The irritant effect of alcohol on the gastric mucosa is accentuated by aspirin which inhibits the local synthesis of prostaglandins (PG).

Central nervous system: This is its major action. It probably acts by dissolving in the lipid membrane of the neurones and perturbing the functions of the ion channels and other proteins. In augments GABA-mediated synaptic inhibition. It also inhibits NMDA glutamate receptors. It depresses the central nervous system in a descending order. In small doses it causes euphoria, freedom from anxiety and worry and may improve social communication; this effect is the chief reason for the popularity it enjoys. This action may be beneficial therapeutically by relieving pathological nervous tension and by improving appetite in anorexia.

Normally, man exercises inhibitions in order to live a disciplined life as desired by the society. Alcohol removes these inhibitions and thus diminishes such characteristics as hesitation, caution and self-criticism. The pattern of behaviour then depends on the environment and the basic personality of the individual. Under the influence of alcohol, mood swings and uncontrolled emotional outbursts are common; the individual may do silly and harmless antics sometimes he can become vicious and anti-social, or reckless. Alcohol is thus incriminated in one out of five crimes of violence.
This initial effect is due to a depression of the reticular activating system. The cortex is thus released from the integrating control or inhibitions required for purposeful activity.

Alcohol reduces visual acuity and interferes with muscular co-ordination even in small doses that do not produce gross intoxication. It impairs the ability of the brain to co-ordinate muscular activity such as typing, standing and hand steadiness. It lengthens the reaction time for both visual and auditory stimuli; in a mildly intoxicated person the reaction time may be lengthened by 10-15 per cent. Hence, even moderate drinking is considered dangerous to public and individual safety. This is more so if the individual is already taking some other central nervous system depressants like sedatives, tranquillizers or analgesics.

Following the ingestion of 60 ml. Of 95 per cent alcohol, the pain threshold is raised by 35-40 per cent. Although it is not an analgesic, it alters the patient's reaction to pain from one of the concern to one of relative detachment.
With increasing quantities, the individual loses all sense of proportion. Difficulty in speech, unsteadiness of gait and complete loss of self control are likely to follow. Large quantities of alcohol ultimately depress the CNS sufficiently to cause unconsciousness. The respiration becomes slow and stertorous, the face becomes pale and cyanotic and the blood pressure falls. Death occurs due the depression of the vital medullary centers, mainly the respiratory center. Some of the CNS effects of alcoholic beverages consumed in large quantities are probably due to substances (ethyl acetate, isoamyl alcohol and butanol) other than ethanol present in these beverages. In epileptics, alcohol may cause convulsions.
Cardiovascular system: Alcohol in moderate amounts causes dilatation of skin vessels by a central action resulting in flushing and feeling of warmth. This effect prevents normal cutaneous vasoconstriction on exposure to cold. Hence, it may be harmful to take alcohol for warning up in cold weather as the body would lose more heat through the dilated skin vessels.

Taken in concentrated from (Brandy 20-30 ml.) alcohol probably stimulates reflexly the vital medullary centers by irritating the pharyngeal mucosa, resulting in a slight rise in blood pressure, acceleration of the heart and an increase in the cardiac output; the effect is transient. For this reason it is used as a household remedy for fainting attacks.
Usefulness of alcohol as a coronary dilator is doubtful. It may relieve anginal pain but the effect is probably due to central action and not due to the dilatation of coronaries. In fact, the euphoria produced by alcohol may give a false sense of well being with a tendency to ignore the warning symptoms since alcohol is known to modify the attitude of the individual towards pain. In large doses alcohol depresses the heart like chloroform or ether. Habitual heavy spirit drinking over many years causes direct injury to the heart muscle and 'alcoholic myocardiopathy'. Since even a small amount of alcohol has been shown to depress the myocardial function in patients with coronary or valvular heart disease, prescription of alcohol to patients with these diseases as a 'tonic' or as a 'coronary dilator' is irrational and unwise. Chronic alcohol ingestion is suspected to increase the risk of developing hypertension.

Liver: In the liver, alcohol brings about:
   - Impaired gluconeogenesis.
   - Reduced synthesis of albumin and transferrin.
   - Increases synthesis of VLDL, with consequent hypertriglyceridemia; and
   - Diminished fatty acid oxidation.

Acute alcohol ingestion inhibits the hepatic microsomal enzyme systems whereas chronic alcohol ingestion stimulates them with resultant increase in the rate of metabolism of many drugs and of alcohol itself. The effect of enzyme induction can be offset by liver damage induced by alcohol and/or nutritional deficiency.
Clinically, hypoglycemia and hepatomegaly are the two important manifestations. Hypoglycemia is liable to occur in people who ingest large quantities of alcohol but eat poorly, particularly if they are on insulin or sulfonylurea drugs for the treatment of diabetes. Hepatomegaly may be due to one of the several causes: simple hepatomegaly (with normal hepatic structure), fatty degeneration, alcoholic hepatitis, cirrhosis or hepatoma.
Alcoholic damage is a direct effect of alcohol on the liver and it is doubtful if a high protein diet protects the liver from the ravages of alcohol. However, it takes many years of heavy drinking to produce cirrhosis. Women seem to be more susceptible than men and there appears to be some genetic predisposition. Elevated serum level of gamma glutamyl transpeptidase (GGTP) is the most sensitive indication of alcoholic liver disease.

Kidney: Alcohol ingestion is known to increase the output of urine. This is probably due to decreased tubular reabsorption of water following depressed A.D.H. production. It also increases the excretion of magnesium and calcium, and decreases that of potassium.

Teratogenic effects: Drinking during pregnancy can have damaging effects on the fetus. The fetus has been described to have "characteristic facial appearance, prenatal onset of growth retardation, mental deficiency and an increase in the frequency of major abnormalities" (the foetal alcohol syndrome). Even moderate alcohol consumption during pregnancy increases the risk of spontaneous abortion and low birth weight.

Other effects: Alcohol has an erroneous reputation as a sexual stimulant (aphrodisiac effect). The feeling of false confidence produced by the loss of inhibitory control is probably responsible for the tendency toward sexual excess observed in intoxication. But as Shakespeare correctly noted in 'Macbeth', "Lechery, Sir, it provoketh and unprovoketh; it provoketh the desire, but it taken away the performance". In fact, it significantly depresses the sexual responcivness in men and women. Further, in men, chronic alcohol ingestion is known to lead to reduction in plasma testosterone levels, impotence, sterility and gynecomastia. It may also produce prostatic congestion causing acute urinary retention. Large doses of alcohol damage the muscle, causing alcoholic myopathy. By stimulating ACTH secretion, chronic ingestion of large doses of alcohol has been shown to lead to 'pseudo Cushing's syndrome'.