Alcohol dependence, alcohol-use disorder, or, as it was formerly known, alcoholism, is a disabling addictive disorder characterized by alcohol consumption that exceeds acceptable cultural limits or injures health or social relationships. Estimates are that the prevalence of lifetime and 12-month alcohol dependence in the United States is 12.5% and 3.8%, respectively.¹ Alcohol dependence is significantly more prevalent among men, whites, Native Americans, younger and unmarried adults, and those with lower incomes. Alcohol dependence affects over 18 million Americans, making it one of the most serious health problems facing physicians today.¹ The total number of Americans affected, either directly or indirectly, is much greater when one considers disruption of family life, automobile accidents, crime, decreased productivity, and mental and physical diseases. With more than 100,000 deaths annually attributed to alcohol misuse, alcohol-related problems are a cause of considerable mortality.² As indicated in Box 143-1, the health, social, and economic consequences of alcohol dependence are alarming.

BOX 143-1 Consequences of Alcohol Dependence

Increased Mortality

• 10- to 12-year decrease in life expectancy

• Double the usual death rate in men, triple in women

• Six times greater suicide rate

• Major factor in the four leading causes of death in men between the ages of 25 and 44: Accidents, homicides, suicides, cirrhosis

Economic Toll (Yearly)

• Lost production: $14.9 billion

• Health care costs: $8.3 billion

• Accident and fire losses: $5 billion

• Cost of violent crime: $1.5 billion

• Total costs (health care, accidents, violence, lost productivity): $136 billion

Health Effects

• Metabolic damage to every cell

• Intoxication

• Abstinence and withdrawal syndromes

• Nutritional diseases

• Cerebellar degeneration

• Cerebral atrophy

• Psychiatric disorders

• Esophagitis, gastritis, ulcer

• Increased cancers of the mouth, pharynx, larynx, and esophagus

• Pancreatitis

• Fatty degeneration and cirrhosis of the liver

• Arrhythmias

• Myocardial degeneration

• Hypertension

• Angina

• Hypoglycemia

• Decreased protein synthesis

• Increased serum and liver triglycerides

• Decreased serum testosterone

• Myopathy

• Neuropathy

• Osteoporosis

• Rosacea, spider veins

• Coagulation disorders

Effects on Fetus

• Growth retardation

• Mental retardation

• Fetal alcohol syndrome

• Teratogenicity

Modified from Hyman SE, Cassem NH. Alcoholism. In Dale DC, Federman DD, eds. Scientific American medicine. New York: Scientific American 1997;III:1-12, 13.

Physicians should consider alcohol dependence when the information provided by the patient and the doctor’s own analysis seems to indicate a missing factor. Often, alcohol dependence is a “hidden” disease. The natural consequences of the alcoholic’s behavior may be disguised by sympathetic family and friends. This allows the alcoholic to target other factors as the “real problem” without identifying his or her drinking behavior. Table 143-1 provides an alcohol dependence screening questionnaire.

TABLE 143-1 The Brief Michigan Alcohol Dependence Screening Test

1. Do you feel you are a normal drinker?	Yes (0)	No (2)
2. Do friends or relatives think you are a normal drinker?	Yes (0)	No (2)
3. Have you ever attended a meeting of Alcoholics Anonymous (AA)?	Yes (5)	No (0)
4. Have you ever lost friends or girlfriends or boyfriends because of drinking?	Yes (2)	No (0)
5. Have you ever gotten into trouble at work because of drinking?	Yes (2)	No (0)
6. Have you ever neglected your obligations, your family, or your work for 2 or more days in a row because you were drinking?	Yes (2)	No (0)
7. Have you ever had delirium tremens (DTs), severe shaking, heard voices, or seen things that were not there after heavy drinking?	Yes (2)	No (0)
8. Have you ever gone to anyone for help about your drinking?	Yes (5)	No (0)
9. Have you ever been in a hospital because of drinking?	Yes (5)	No (0)
10. Have you ever been arrested for drunk driving or driving after drinking?	Yes (2)	No (0)

Alcohol dependence is indicated by a score above 5.

Modified from Hyman SE, Cassem NH. Alcoholism. In Dale DC, Federman DD, eds. Scientific American medicine. New York: Scientific American, 1997:III, 1-12, 13

The etiology of alcohol dependence remains obscure. It represents a multifactorial condition involving genetic, physiologic, psychological, and social factors, each of which seems to be important. Serious drinking often starts in younger people; approximately 35% of alcoholics develop their first symptoms between 15 and 19 years of age, and more than 80% develop their first symptoms before age 30.³

Although alcohol dependence is most common in men, the incidence has been increasing in women. Although the figures were once more disparate, the female- to-male ratio for alcohol dependence has tapered to 1:2.^1,² Women generally seem to develop disease at a lower level of intake than men do. This may be partially because of women’s lower volume of distribution for alcohol and may also be related to increased gut permeability to endotoxins.⁴

Research indicates that genetic factors may be particularly important.⁵ The finding of a genetic marker for alcohol dependence could result in the diagnosis of the disease in its initial and most reversible stage. Some case-control studies suggest that non–gender-based gene polymorphisms encoding cytokines and other immune modulators may play a role in the predisposition to alcoholism. The gene patterns associated with risk reveal that antibody-mediated mechanisms may play a role in disease pathogenesis.⁴ The genetic basis of alcohol dependence has also been supported by the following:

A number of studies have shown that the incidence of alcohol dependence is four to five times more common in the biological children of alcoholic parents than those of nonalcoholic parents.⁵ Although it would be ultimately useful, knowledge of family history suggests that clear evidence of a biological marker may not be necessary for the implementation of a relatively innocuous primary prevention program.

Intoxication and Withdrawal

The signs of alcoholic intoxication are typical of a central nervous system depressant: drowsiness, errors of commission, disinhibition, dysarthria, ataxia, and nystagmus. Fifteen milliliters of pure alcohol (the equivalent of 1 oz of whiskey, 4 oz of wine, or 10 oz of beer) raise the blood level of alcohol by 25 mg/dL in a 70-kg person. Table 143-2 shows the effects of varying blood levels of alcohol.

TABLE 143-2 Effects of Varying Levels of Blood Alcohol

BLOOD LEVEL (MG/DL)	EFFECT
<50	No significant motor dysfunction
100	Mild intoxication—decreased inhibitions, slight visual impairment, slight muscular incoordination, slowing of reaction time
100	Legally intoxicated in most jurisdictions
150	Ataxia, dysarthria, slurring of speech, nausea and vomiting
350	Marked muscular incoordination, blurred vision, approaching stupor
500	Coma and death