Alcoholism

Alcoholism is a behaviour pattern characterized by uncontrolled drinking of alcoholic beverages to the extent of impairing health and social functioning. Alcoholism is thus one extreme in a range of drinking patterns that vary among individuals in degree of dependency and tolerance, and in a host of other ways; eg, timing or beverage choice. Groups and countries also differ in drinking patterns, norms and standards, and forms of regulation and control. The term "problem drinker" is used to refer to persons not necessarily physically addicted to alcohol but experiencing (or causing) health, social or other problems.

History of the Use of Alcohol

The process of fermenting sugar-containing liquids to make alcohol has been known since the beginning of recorded history and is today practised by many preliterate people around the world. The ancient Egyptians drank both wines and beers, as did earlier peoples elsewhere in the Middle East. Of 139 societies around the world, at least 121 apparently consume alcohol in some beverage form. Stronger drinks, produced by distilling fermented liquids, likely first appeared during the Middle Ages in the Middle East or South Asia (see distilling industry).

Sociologists have found that the amount of drinking differs among the societies of the world, and that this variation can be explained by technological complexity and other factors. Although more advanced societies are more likely to use alcohol, drunkenness is more widespread among less complex societies, apparently because of anxiety induced by economic uncertainties and other hazards of subsistence. The introduction of distilled beverages from Europe has also tended to disrupt traditional drinking practices in non-Western societies. More controlled drinking is associated with tighter social organization, particularly where alcohol use is incorporated symbolically into collective ceremonies. In industrial societies, the greater personal freedom and wealth people enjoy, together with the requirement for more organized and tightly scheduled work activity, has led to pressure to regulate and limit alcohol use.

Scientific Perspectives on Alcohol Use

Ethanol, popularly known as "alcohol," is actually one of a class of organic compounds consisting of a hydroxyl group attached to a carbon atom. Ethyl alcohol (CH3CH2OH) is the principal pharmacological ingredient of alcoholic beverages. Other alcohols and related substances are present in small quantities, and these may contribute to the physiological and psychological effects of alcohol, including the "hangover." One ingredient, thujone, a component of wormwood oil, is a potent intoxicant present in absinthe, and in lesser quantities in vermouth. In wines, yeast acts on natural sugars to produce ethanol; wines are made not only from grapes, but from many other fruits as well, and have a maximum alcohol content of about 14%, as this is the concentration at which yeast is killed (see wine industry).

Fortification, in which a portion of the must is distilled and then returned to the original liquid, can increase the alcohol content of wine, as in the production of sherry. Beers are typically lower in alcohol content and are produced from starchy plants by first breaking down, with the help of an enzyme, the complex carbohydrates into simpler sugars. Finally, beverages containing up to 95% alcohol can be produced by distillation; ie, the heating of a fermented liquid to the point that the portion containing ethanol will evaporate and condense back to a liquid state. Popular distilled beverages in Canada include rum, made from sugar cane, and whisky, produced from barley and other grains.

An alcoholic beverage is absorbed rapidly into the bloodstream through the stomach wall and the small intestine because it does not undergo any digestive processes. The rate of absorption can be modified by, among other factors, the type and amount of food present in the stomach. Recent ingestion of a fatty meal substantially slows absorption of alcohol. From the blood, alcohol is distributed to all parts of the body and absorbed until an equilibrium is achieved between the alcohol in the blood and that in various organs. Alcohol is eliminated slightly (10%) through expiration, perspiration and urination, but most of it is metabolized in the liver, ultimately producing water, carbon dioxide and energy.

The degree of intoxication produced by ethanol reflects the concentration of alcohol in the blood, which is primarily a function of the amount ingested, the volume of blood in the body, rates of absorption and metabolism, and time since ingestion. Depending on body weight, an adult male could have a blood alcohol concentration of 0.06% after 3 typical drinks of an alcoholic beverage. Findings on physiological and psychological correlations of these small doses of ethanol are inconsistent, but at larger doses there is no doubt that alcohol becomes a central nervous-system depressant. The evidence suggests that a blood alcohol level of 0.1% affects some of the motor areas of the brain; eg, speech, balance and manual dexterity. An alcohol concentration of 0.2% depresses all the motor centres and that area concerned with emotions. At 0.45% the entire area concerned with perception is depressed and coma results. At 0.7% the centres controlling heartbeat and breathing are depressed and the person dies.

In general, the findings of psychological studies of the effects of ethanol, particularly at lower doses, on complex behaviour (eg, aggression, sex) are difficult to interpret. Research on the effects of alcohol on emotions and "moods" are likewise inconclusive. Many laboratory studies have ignored the situational variables (eg, the presence of others, social relationships with these people, and so forth) that set the context for drinking in everyday life. There is also evidence that a person's expectations of the effects of alcohol play a large part in the quality of the drinking experience.

Studies of national drinking patterns and cross-cultural research on alcohol use have revealed considerable societal variation in behavioural responses to alcohol. The definitions held by a group or a society about the functions, uses and effects of alcohol almost certainly significantly affect the responses of persons to dietary alcohol. In some societies (eg, Italy, where alcohol is defined largely as a food) wine is consumed with meals and seems to have little disruptive effect on behaviour. In Scandinavia, especially Finland, alcoholic beverages are traditionally defined as intoxicants, and the consumption of distilled beverages, largely apart from meals, can lead to explosive or violent episodes. In beer-drinking countries of Europe and North America, alcohol is largely defined as a facilitator of social interaction. However, it would be premature to conclude that the strength or type of beverage is the direct or indirect cause of behavioural response. Among certain rural Bolivians, for instance, the normal beverage contains 95% alcohol, and yet the response to gross intoxication in social situations to this unusually strong drink is passiveness, and disruptive behaviour is extremely rare.

Alcoholism and Alcohol Abuse

Researchers approach the problem of alcoholism from a variety of perspectives: biological (how alcohol affects the body), psychological (how it affects the mind) and sociological (how alcohol is provided and consumed in society). It is clear that some persons develop a tolerance for alcohol, and that increasing amounts are required to achieve the same degree of perceived intoxication. Some people also become dependent on alcohol; a change occurs in their body cells, which have become adapted to alcohol. Withdrawal symptoms include craving, shakiness and increased anxiety (the hangover can be considered a mild form of withdrawal). More extreme reactions to cessation of long periods of heavy drinking can include nausea, vomiting and seizures. Delirium tremens ("DTs"), which combines several of these withdrawal symptoms, can include hallucinations and other unpleasant sensations.

Some chronic problems resulting from prolonged heavy drinking are considered manifestations of alcoholism; these include nutritional deficiencies, digestive problems, inflammation of the liver and pancreas, anemia, impotence, neurological dysfunctions and the newly discovered fetal alcohol syndrome. Other problems related to heavy drinking include motor vehicle crashes, other forms of accidental death and injury, suicide and crime (see impaired driving).

Despite much research, the causes of alcoholism remain obscure. Alcoholism, in fact, is better conceived as a set of related problems, each of which differs somewhat in characteristics, causes, prognosis and treatment. Cultural factors (eg, religion, attitudes toward alcohol and drinking problems) are related to rates of alcoholism. Social phenomena such as the practices of family and friends and the nature and strength of punishments and rewards for drinking also affect alcohol use and abuse. Limitations or inducements regarding the availability of alcohol, such as income and regulations on manufacture, distribution and sales, appear in some studies to influence the extent of drinking and alcohol problems. Individuals also differ in their predisposition to alcohol intoxication and dependence, and for this reason much psychological and physiological research has been conducted. There is little evidence, however, that certain personality types are predisposed to alcoholism.

Drinking in Canada

About 75% of Canadian adults consume alcoholic beverages at least occasionally. Canada has been classified internationally as a beer-drinking country, as beer and ale account for 51% of the consumption of absolute alcohol. Statistics on alcohol consumption are usually expressed in terms of absolute alcohol. Since beer and spirits, for example, differ greatly in alcohol content (about 5% for beer versus 40% for spirits), it is necessary to convert both these figures to absolute alcohol. That is, 100 litres of beer would represent only 5 litres of absolute alcohol, whereas only 12.5 litres of whisky would contain a comparable quantity of alcohol. In addition to beer and ale, another 34% of absolute alcohol consumption represents use of distilled spirits. Although in countries such as Turkey, Poland and Israel the majority of alcohol consumed is in the form of spirits, in absolute terms Canadians are among the world's leaders in spirits consumption also, since many of the countries specializing in spirits have relatively low levels of alcohol consumption overall. Canadians on average drink only 9 litres of wine apiece annually, compared with 62 in Portugal and 67 in France. In general, however, the drinking patterns of the countries of the world are becoming more similar to one another; in Canada this meant that consumption of beer was declining and that of wine increasing until the 1980s. Canada is generally similar to northwestern European industrial countries in alcohol consumption levels.

Canadians drank 7.4 litres of absolute alcohol per adult in 1997, a decrease from 9 litres in 1991, although in 1950 the figure was less than 7 litres per capita. It must be noted that official figures on alcohol consumption generally do not include beer and wine of home manufacture, nor alcoholic beverages purchased abroad and brought into Canada, so the 7.4 litres statistic is probably an underestimate. Nevertheless, alcohol use in most countries, including Canada, is relatively moderate today compared with that of the 18th and 19th centuries. It is difficult to obtain figures on early drinking in Canada. In the 1870s provinces officially recorded only about 5 litres per year, but this statistic does not include home-manufactured cider and beer, which in a largely rural, agrarian country could have accounted for a major proportion of consumption. Moreover, in other countries, such as Sweden and the US, the growth of the Temperance Movement in the 19th century coincided with a trend of falling alcohol intake.

Earlier, in the 1830s in a typical district of Upper Canada (Bathurst), there were 6 distilleries serving the area. Each of these produced about 60 gallons a day of whisky and other spirits, which would yield a per capita consumption of 13.4 litres of ethanol for people over age 15. This figure is half the official American consumption of 26.9 litres in 1830, but the Canadian (Bathurst) figure does not include beer, cider or wine. Thus, although alcohol consumption has increased since the end of prohibition, it has levelled off and is probably far less than the high levels of consumption prior to the beginning of the temperance movement. Moreover, the types of beverages consumed have been changing, reflecting a long-term trend away from distilled and toward milder beverages.

Approximately 4% of adult drinkers are alcoholics, a figure calculated from the known incidence of mortality caused by cirrhosis of the liver, and therefore probably a conservative estimate. International comparisons of alcoholism generally rely on data on cirrhosis of the liver (the "Jellinek formula"), and it is known that cirrhosis rates are highly correlated with overall consumption levels. Therefore, rates of alcoholism for the countries of the world generally reflect consumption levels, so alcoholism in Canada is about average for Western countries. About 2200 persons annually die in Canada from cirrhosis of the liver, which is equivalent to a death rate per year of 8.0 per 100 000 population. A few hundred more die of other alcohol-related conditions (poisoning, automobile accidents, etc). Rates of death caused by cirrhosis of the liver increase markedly with age and are higher in urban areas and in the west and north, the areas with the highest levels of alcohol consumption in Canada.

Canadians report in surveys they have about 4 drinks per week on the average, although this is undoubtedly an underestimation. Sales figures would indicate that Canadians actually drink more like 10.8 drinks per week, over twice as much. Moreover, actual consumption probably exceeds sales, since a fair amount of alcohol is brought over the border from the United States, where duty-free shops and considerably lower prices attract consumers. Today, also, many Canadians make their own beer and wine at home.

It is true that tourists drink some alcohol, especially in the Northwest Territories, but traffic in the opposite direction across the US border is surely equally large. Sales data and survey data do concur, however, that consumption of beverage alcohol has declined in recent years. Canada is a complex and varied country and it manifests considerable variation in drinking practices. Men report that they drink 3 times as much alcohol on the average as do women.

In the more traditional Atlantic region the sexes differ by a factor of 4, whereas in BC the sex difference in drinking is less. These reported sex differences in consumption must be treated cautiously, but death rates for cirrhosis are also twice as high for males. English-speaking Canadians drink more than linguistic minorities. For males, alcohol consumption remains fairly high until the fifth and sixth decades of life, whereas the amount of drinking declines steadily with age for women. Married people drink less than the single, divorced or separated.

Other factors appear to influence alcohol use, in particular social class and religion. For women, increases in the level of education, income and occupational skill lead to a greater use of alcohol, although studies suggest that a higher proportion of female heavy drinkers is found in the low-income population. Men in the intermediate levels of occupation and education have the highest levels of alcohol consumption. In general higher education and income lead to more frequent drinking, though not to consuming greater quantities at one sitting. Jews are the least likely to abstain from alcohol of any religious group, but they also have the lowest rates of alcoholism. This immunity to addiction seems to result from the ritual uses that alcohol is put to in orthodox religious practice. Persons with no religious affiliations are the heaviest drinkers. For men, recent illness is more common among heavier drinkers, whereas the reverse is true for women; this difference probably merely reflects, however, the increase in illness with age and the different effects of aging on alcohol use for men in contrast to women.

Responses to Alcohol Problems

Prior to the 19th century in Canada, the use of alcohol was largely taken for granted, and cider, beer and wine were consumed every day. Addiction to alcohol was ignored, since regular use of beverage alcohol was the accepted norm. The exception to this generalization was the early attempts (by both French and British authorities) to regulate the drinking of native people. The drinking of distilled spirits had become more common by the turn of the 19th century, and temperance movements in Britain and the US advocated moderation in the use of alcoholic beverages. The churches, particularly the Baptists and Methodists, became active in the temperance cause, which eventually advocated total abstention from alcohol and the legal prohibition of the "liquor traffic." At this point, conflict between social groups (eg, religious, ethnic and political) began to affect the debate, and plebiscites for prohibition revealed large interprovincial differences in support of the measure. Québec was overwhelmingly opposed to prohibition, while PEI and Nova Scotia were heavily in favour. Prohibition of spirits became national policy during WWI, although much illicit manufacture and evasion occurred.

Shortly after WWI the provinces began replacing prohibitory legislation with a system of government-controlled distribution and licensing. The ostensible purpose of this role for government was maintenance of public health and order, but the actual function today is largely one of raising revenue and dispensing political patronage. Research does show, however, that the pricing policies and the control of the hours and days of sale do have some impact on alcohol consumption and problems.

Treatment of Alcoholism

A variety of programs to treat alcohol-related problems exists in Canada. Some programs treat alcoholics directly, while others offer referrals to treatment facilities, provide counselling for families of alcoholics or provide programs on alcoholism prevention, drinking and driving, etc. Alcoholics Anonymous (AA) and a variety of government-sponsored programs (some affiliated with health-care institutions, others existing only to treat alcoholism) are directly concerned with providing assistance to alcoholics. Government programs have been classified as, first, detoxification (inpatient care for 2 or 3 days); second, short-term residential (inpatient treatment or rehabilitation for a few days or weeks); third, long-term residential; and fourth, outpatient clinics.

In the last decade the trend has been toward more outpatient treatment and less hospitalization, as has been the direction of treatment for most physical and mental diseases. A little research has been done, some of which supports the effectiveness of outpatient treatment and some of which does not. One is forced to conclude that a major motive for such treatment is to reduce costs and that the effectiveness is a secondary consideration. One recent study found a ratio of day-service patients to inpatients of 1:3, with a greatly reduced length of stay for inpatients. About 10% of Canada's addicted population is treated annually by one or another of the alcoholism programs. Males are 6 times as likely as females to be admitted and the mean age of admission is 44 years.

The costs and benefits of a commodity such as beverage alcohol can be analysed in economic and noneconomic terms. Through its monopolies on sales, the governments of Canada earn about $3 billion a year in profits, about two-thirds going to the provinces. Some revenues also accrue to farmers growing fruits and grains, as well as to brewers, vintners and distillers, and to the beverage service industry. Workers in alcohol production earn a half-billion dollars in wages and salaries, and alcohol advertising is a big business. Exports of Canadian spirits, particularly whisky, and more recently beer, have earned valuable foreign exchange. On the negative side, costs to the Canadian health-care system that are directly or indirectly attributable to alcohol have been estimated at $2 billion.

Alcohol abuse has also been blamed for excessive costs in other areas such as law enforcement, social welfare and traffic accidents. Lost production in industry due to alcohol probably costs more than $1 billion a year. Many costs and benefits are more difficult to quantify. Wine is indispensable to religious ceremonies in some groups, but is considered anathema by others. Social and psychological benefits of alcohol use are obvious, as is the harm caused by excessive and intemperate use. Moderate drinkers are less liable to suffer heart problems than abstainers and they appear to be healthier and live longer on the average. Heavy drinkers suffer many health problems and have a shorter life expectancy.

Types of Therapy

Therapies for alcoholism include drugs (eg, Antabuse), which cause unpleasant reactions in the drinker; individual psychotherapy; behavioural techniques (eg, learned aversion); and group therapy. The efficacy of these therapies is controversial.

Studies show that from a third to 70% of patients show improvement, although whether abstinence or "social drinking" is the objective has not been decided. It must be kept in mind that alcoholism is a condition of fluctuating severity, and that sufferers are likely to seek treatment during times when they are especially needful of treatment. Hence at subsequent times they will predictably be better, but it is difficult to attribute the improvement exclusively to the therapy received. The literature on treatment outcomes is more optimistic now than formerly, and tends to be increasingly sceptical of Alcoholics Anonymous, but professional self-interest could be a factor here.