The Business of Alcohol

The liquor industry is big business.  In 1998, Americans spent more than $95.8 billion on alcoholic beverages in bars, taverns, restaurants, and in take-out stores.  Beer is the most popular form of beverage alcohol, followed by wine and distilled spirits.  The percentages of beverages consumed is as follows:

In 1999 (the most current reporting period for such information) the average American consumed 27.5 gallons of beer (which equates to 1.24 gallons of ethyl alcohol), 2.4 gallons of wine (0.31 gallons of ETOH), and 1.5 gallons of distilled spirits (1.5 gallons of ETOH) for a total of 31.4 gallons of alcoholic beverages (2.18 gallons of ETOH).  Contrast this to the average consumption for adults of the following products: 26.6 gallons of milk, 7.0 gallons of tea, 26.6 gallons of coffee, 47.3 gallons of soft drinks, 6.4 gallons of juices, 8.8 gallons of bottled water, and 27.5 gallons of tap water.

The liquor industry itself is now spending $1.6 billion annually on advertising alone, and has spent this much or more since 1990.  In January of 1992, then U.S. Surgeon General, Antonio Novello, took aim at this fact by calling on the liquor industry to tone down their advertisement of alcohol.  She cited the fact that so many of the commercials use imagery that tends to entice youth to drink.  She particularly viewed the use of sex (bikini-clad women in virtually all beer ads) and rock-and-roll as being responsible for giving youth the impression that to have fun and fit in with the right crowd, all you have to do is drink.  Additionally, she raised great concern that the images of skiing, race car driving, roller-skating, and the like also give the wrong message - that you do these things better with drinking.  The industry itself has responded quite angrily, citing the campaigns they have waged to advocate the responsible use of alcohol.  While many of these campaigns do have strong messages against drunk driving, none of them advocate abstinence from alcohol, especially for under aged youth.

Probably more of a concern, however, is the fact that so many adolescents and adults continue to view alcohol as a social drink, not the problem drug that it can be.  Drinking is viewed as being a right of passage from adolescence to adult life.  There are few places you can go today where alcoholic beverages are not served.  There are also few people who recognize the physical and psychological changes that occur when they drink.  Many people view alcohol as a stimulant, a quick "pick me up."  Most people report that they actually act more responsibly, and also drive with greater care when drinking, in spite of medical evidence to the contrary.  It’s time that society take greater steps to educate people to the drug and its effects, with the hope that knowledge will help people know when to drink, when not to drink, and the problems that drinking can create.

Acute Effects of Alcohol

As a drug, alcohol affects anyone who drinks in virtually the same way.  The differences that do occur can be traced to the differences in how alcohol is absorbed, distributed or eliminated by the body.

ABSORPTION - once alcohol is swallowed and enters the stomach, this process begins.  Even though it contains calories, alcohol requires no digestion and passes readily through the walls of the stomach, where tiny blood vessels pick up the alcohol.  Approximately 20% of alcohol consumed enters the blood in this fashion, while the rest must pass through the stomach into the small intestine to be absorbed.  Anything that causes the alcohol to stay in the stomach will delay absorption.

Mixed drinks means the alcohol is more dilute, slowing the absorption.  Food in the stomach will delay the absorption, but this in turn may mean that the peak blood alcohol concentration (BAC) won’t be reached for several hours.  Sweet mixes take longer to digest.  The higher the concentration of alcohol, the faster the absorption.  The rate of consumption also affects absorption - gulping drinks causes a more rapid rise of blood alcohol.  Straight shots of liquor may paralyze the pyloric valve at the base of the stomach, causing it to stay closed and keep the contents of the stomach from moving.  Carbonated mixes or sparkling wines may speed up the absorption process by relaxing the pyloric valve.

Mood and emotions may also affect the digestive process.  Anger, fear, stress and fatigue can cause the absorption to be delayed; happiness, excitement and the like can cause the process to speed up.

DISTRIBUTION - once alcohol reaches the bloodstream, it then travels to all body parts.  Organs with higher concentrations of water, or dense networks of blood vessels and a richer blood supply (brain, kidneys, liver, and lungs) reach the same blood alcohol concentration (BAC) of the blood very rapidly.  Intoxication occurs as the BAC increases faster then the body can remove the alcohol from the blood.

The BAC remains at a peak until equilibration occurs (the equal distribution of alcohol to all body tissues).  Body water is the key to an increasing BAC.  The more body water, the more dilute the alcohol, the lower the rise in BAC.  Therefore women, with more adipos (fatty) tissues and less muscle (water) tissue, generally achieve higher BAC’s and a greater level of intoxication, though the climb to this BAC level may be slower than their male counterpart.  Body weight is also and important factor in BAC’s - the more an individual weighs, the lower the BAC.

ELIMINATION - alcohol is a toxic product - the LD-50 (lethal dose) of alcohol is between 12-19 ounces of pure alcohol (the equivalent of about a fifth and a half of 80 proof spirits or a case of beer).  The body will begin to eliminate it immediately upon intake.  Since water is the primary mechanism used to dilute and eliminate alcohol, salivation will increase, diluting the alcohol entering the system.  This is also why alcohol may burn going down - the cells of the throat burst to give up their water (this effect is most noticeable with straight spirits rather than beer or wine).  Two to five percent of all alcohol is eliminated unchanged in urine, perspiration, and respiration.  The remainder must be eliminated through the detoxification and oxidation process.

The liver is the only organ that can detoxify alcohol, that is, change ethyl alcohol to acetaldehyde, acetaldehyde to acetic acid.  It detoxifies 95 to 98% of all alcohol that enters the system.  Once the liver has detoxified alcohol to acetaldehyde, acetaldehyde to acetic acid, all of the organs that possess a dense network of blood vessels can burn (oxidize) the acetic acid.  The liver oxidizes about 75% of the alcohol consumed; other body organs eliminate about 20% of the alcohol.  The metabolic rate for elimination is about 1/2 oz. per hour.  This may vary according to age, sex, the time of day, race, health of liver, other drugs in the system, food, menstrual cycle, and oral contraceptives.  Since most of the equivalent drinks contain about one-half ounce of ETOH, a good rule of thumb is "one drink leaves the body every hour."  The breakdown equations for the removal of alcohol are found in Box A.2.

This process occurs at a fairly constant rate.  Nothing, except intravenous administration of fructose or dialysis of the blood, will increase the speed of removal of alcohol.  Exercise won’t sober you up, just makes you a sweaty drunk.  Coffee only allows the stimulant to have greater effect on the body, since the body can only remove one drug at a time (alcohol is always the priority drug when other drugs are present in the body), thus making you more alert but still drunk and impaired.  A cold shower does nothing to change the metabolism, just make you cold and wet, but still drunk.

Acute Physical Effects of Alcohol

Alcohol does two things when it comes in contact with the body, it irritates and sedates.  It is a depressant drug, not a stimulant.  Its primary action is to cause central nervous system depression, which results in change of all body systems.  It is an irritant, causing discomfort to all tissues it comes in contact with.  There is no system that alcohol does not effect.  Some systems show a greater effect than others, but all are impaired by the presence of alcohol in the body.  The following are examples of the types of change caused by alcohol in the body.

Digestive System - the lining of gastrointestinal tract is noticeably effected by the presence of alcohol. As an irritant, alcohol causes the stomach to produce a larger than normal flow of hydrochloric acid.  This can create gas and indigestion as a short-term effect.  Longer exposure to this effect can result in the development of ulcers.  Low concentrations of alcohol also stimulate secretion of additional gastric juices which can aid the digestive process.  Approximately two glasses of wine before a meal will enhance digestion.  More than this amount, however, will actually inhibit these same enzymes, causing poor or improper digestion to occur.

Heart and Circulation - low doses of alcohol initially  increase the heart rate and blood pressure, then begins to sedate the heart muscle.  As more alcohol enters the system, the pumping power of the heart is reduced and this condition can cause irregular heart rhythms which can be detected on an EKG reading.  This effect occurs even in healthy drinkers, and is known as the "Holiday Heart Syndrome," since many social drinkers notice this change in heart rhythm during excess drinking at various holidays.  Each year, many hundreds of drinkers report to emergency room settings, fearing a heart attack, but actually suffering from a bout of excess drinking.

Moderate doses of alcohol dilate blood vessels on the surface layer of the skin,  causing reddening or a flushed look as well as rapid heat loss.  Higher doses actually decrease internal body temperature and impair the body’s ability to regulate heat.  Many people mistakenly believe that shots of straight spirits during cold weather warm the body, when in actuality the body is losing heat, and the system is more at risk for frostbite and other cold weather conditions.

Each time you drink, red blood cells are killed by the toxic effect of alcohol.  Three drinks actually kills as many platelets as the body produces in a given day.  As these red cells and platelets float in the system, the body absorbs some and re-uses the components to make new blood cells.  However, as the body is doing this naturally each day, the additional die off caused by alcohol cannot always be absorbed.  Some of these cells will begin to aggregate in small vessels, particularly the capillaries, slowing or actually stopping circulation in some of these finer vessels.  This may cause damage to the nerve endings, the heart, and muscles.  This condition is known as "sludge" and is irreversible.

Recently, the wine industry has been promoting the health benefits of red wine on the heart.  A "Sixty Minutes" story actually talked about the lower rate of heart disease in France as a result of drinking beaucoup red wine (Beaujolais).  Apparently, a chemical in red wine called resveratrol, works to lower cholesterol.  After the story, sales of red wine showed a 30% increase.  The wine council in the United States also released a booklet for distribution at liquor stores called "The Benefit of Wine on the Human Heart."

What they don’t tell you is that resveratrol is not unique  to wine - you don’t have to drink red wine to get the benefit - grape juice also has the chemical, which actually comes from the skin of the red grape.  The concentration of the chemical is higher in red wine, but you add the negative benefits of the toxic effect of the ethanol.  You just have to consume more juice for the same result, at least until modern science finds a way of concentrating the resveratrol in some other form.

Endocrine - there are noticeable effects on the system of glands and organs that secrete products which regulate our body.  In the pancreas, insulin is secreted to control the level of blood sugar.  Because of its irritant effect, alcohol causes the pancreas to release additional insulin, which depletes blood sugar, causing a condition known as hypoglycemia (low blood sugar).  In mild cases, the symptoms are sweating, nevousness, weakness or confusion.  More severe cases show symptoms of abnormal behavior, loss of consciousness, severe confusion or a coma.  This is also a critical concern for adolescents who drink because blood sugar is necessary for the brain to function properly.  If the blood sugar drops long enough, brain damage or retardation can occur.  Children under the age of 10 would be most susceptible to this condition, affecting the intelligence and motor areas of the brain.  Even small amounts of alcohol can begin the development of this condition.  Alcohol use in any form by pre-teens and teenagers should be discouraged.

When the body suffers from a period of low blood sugar, it responds quickly to stabilize this condition.  The liver will begin to produce additional supplies of glycogen, the type of sugar used by the body.  Fat cells actually begin to accumulate in the liver because of this, and when the body then overproduces glycogen, a condition called hyperglycemia occurs.  In a normal, healthy individual, we may see increased activity, bizarre behavior, and a dry-mouth.  If a person is diabetic, coma or death can occur from this condition.

Anyone who drinks notices the increase in trips to the bathroom.  This increased urine output is not caused by the effect of alcohol on the kidneys, nor is it caused by the increased fluids in the system.  In the pituitary gland, a hormone is released that regulates the action of the kidneys.  Alcohol causes the pituitary to release too little of this hormone.  As a result, the kidneys produce a larger than normal amount of dilute urine to pass.  Without the hormone to regulate the normal flow, the kidneys trigger a response to void, even when there is actually little urine to pass.  This effect is most noticeable when BAC is rising.

In women, production of the hormone oxytocin is inhibited by alcohol.  This hormone is responsible for stimulating contractions of the uterus, thus its absence may prevent natural labor and delivery.  Alcohol has been used to control premature labor, but problems to the fetus caused by the mother drinking have made such use rare and actually discouraged.  Oxytocin is also responsible for milk production in a new mother.  Its absence can prematurely stop and dry up milk flow.

In men, alcohol lowers testosterone by inhibiting its production as well as causing the liver to remove testosterone more rapidly.  Its absence may lead to impotence as well as reduced sperm production.  Surprisingly, many problems related to infertility in both males and females is being found to be attributable to the use of various psychoactive chemicals, including alcohol.

Central Nervous System - being the largest water carrying organ, the effects of alcohol on the brain are most noticeable.  The brain is comprised of a variety of sections, each having control over various body aspects.  As a depressant drug, alcohol sedates the brain from the outside in, from the cerebral cortex (the outermost area of the brain) to the medullar functions (the deepest brain functions). Box A.3 shows the various levels of activity that are effected by the presence of alcohol in the brain.  As each level is effected, the level below it begins to take charge of the body’s control.  Many of the behaviors that are exhibited are related to this anesthetic effect.

The outermost level controls our intellect, our reasons and our moral codes.  In normal situations, this allows us to make rational decisions and keeps us from doing or saying things that are inappropriate.  As alcohol puts this area to sleep, we tend to say things we might otherwise not say.  We tend to display behavior we do not usually exhibit.  We tend to begin acting out in a more sexually provocative manner.  For years, alcohol has been believed to be an aphrodisiac, a drug that enhances sexual behavior.  Actually, it is the loss of our intellect and moral reasoning that allows us to act on impulses that we have.

The next level houses our emotions.  As the intellect is put to sleep, the emotional level takes control.  This is why so many people believe alcohol to be a stimulant drug.  People who drink usually say and do things with more energy and with more emotion.  This is not stimulation, but the fact that the underlying emotions now take charge of the body and the fact that the intellect which controls the flow of emotions is now depressed.  This is why some people who drink get wild, crazy, laugh, and generally have a good time.  It is also why some people who drink get angry, hostile and violent.  The Latin saying, "en vino veritas," in wine there is truth, relates to the belief that alcohol allows us to see the true nature of the person when they drink.  We may see a truer picture of the person inside, but the behaviors are still drug-affected.

The next level controls motor coordination.  The effects of alcohol on this area are of great concern, particularly as it relates to driving.  As little as two drinks begins to impair motor coordination.  People begin to lose balance and judgment, and the ability to perform complex tasks (like driving) are greatly impaired.

At the level where the semi-voluntary systems are controlled, some very noticeable effects occur.  The semi-voluntary systems are those which the body controls, but systems which we can consciously control as well.  For example, swallowing and blinking are controlled by the body, but we can perform these tasks on command.  When alcohol impairs this level, such actions stop.  That is why people who drink too much wake up with a dry mouth and red eyes.  The alcohol has caused the body to stop salivating, thus we don’t lubricate the mouth.  It has also stopped the eyes from blinking, thus they dry out and become red and irritated.

The involuntary systems are those which only the body controls, but are not necessary at all times to maintain healthy functioning.  Such systems include the gastrointestinal system and the reproductive system.  When necessary, the body can stop their actions in order to maintain vital functions.  When alcohol sedates this level, the body simply pulls the plug on such systems until the alcohol is dealt with.  This is why many people feel nausea and vomit after a period of heavy drinking.  The food stuff in the stomach was not digested appropriately, and the next morning, as the body works to bring the system back to work, it is confronted with a full or partially full stomach.  Instead of digesting it, the stomach performs a routine house-cleaning chore and expels the food.  In the reproductive system, not only is the libido effected, but the physical ability to perform sexually is also lost.  The fact that alcohol reduces inhibitions makes many individuals feel more sexually inclined, but with enough alcohol, the physical ability to perform sexually is lost.

The final level of the brain houses controls for the vital functions - heart, respiration and the action of the brain itself.  If alcohol were permitted to sedate this area, death would occur.  The body has the ability to stop this process simply by creating a period of unconsciousness or coma if necessary.  It would take a high tolerance to alcohol to allow this to occur, and many inexperienced drinkers simply pass out well before reaching this extreme.  However, many adolescent drinkers, because of the way they drink to get drunk, put themselves at high risk for this effect.  Each year, several hundreds of adolescents nationwide die as a result of acute alcohol poisoning.

The effect on the central nervous system can best be described by  looking at the typical effects of alcohol by contrasting the number of drinks consumed with the corresponding blood alcohol concentration (BAC).  Table A.4 shows these effects.

Some important facts come out of this chart:

1.    At the three drink level, motor functions are already being impaired, even before a person reaches the point of legal intoxication.  This effect is most pronounced if a person is engaged in more than one task at the same time, e.g. -  driving a car and lighting a cigarette.  There is also a noticeable decrease in the reaction to visual and auditory stimulus.  In other words, being able to see a light turn red and stop safely is greatly impaired, or hearing a train whistle and being unable to realize that a train is coming could prove fatal.

2.    At the five drink level, the senses are impaired physiologically - the eye’s ability to discriminate intensities of light is reduced, and there is lower resistance to glare (it takes longer to readjust from  bright light, thereby causing momentary blindness).  With the ears, there is a lesser ability to distinguish sounds, especially high sounds, and a person would be unable to judge distance or direction based on sound.

3.    At the seven drink level, a BAC of .20 and above is considered a key diagnostic aid for alcoholism.  While there is no one definitive indicator of alcoholism, a .20 BAC is highly significant in its correlation to alcoholism.  It requires a high body tolerance to alcohol to achieve this level.  The exception occurs with social drinkers who rapidly ingest large quantities of alcohol.  Such a rapid rise may prove fatal to the non-alcoholic individual who lacks body tolerance.  Over 400 adolescents die each year due to acute alcohol intoxication.

Alcohol and the Effects on Sleep

The average adult sleeps 7.5 to 8 hours every night. Although the function of sleep is not completely know, abundant evidence demonstrates that lack of sleep can have serious consequences, including increased risk of depressive disorders, impaired breathing, and heart disease. In addition, excessive daytime sleepiness resulting from sleep disturbance is associated with memory deficits, impaired social and occupational function, and car crashes. Alcohol consumption can induce sleep disorders by disrupting the sequence and duration of sleep states and by altering total sleep time as well as the time required to fall asleep (i.e., sleep latency).

Before discussing alcohol's effects on sleep, it is helpful to summarize some basic features of normal sleep. A person goes through two alternating states of sleep, characterized in part by different types of brain electrical activity (i.e., brain waves). These states are called slow wave sleep (SWS), because in this type of sleep the brain waves are very slow, and rapid eye movement (REM) sleep, in which the eyes undergo rapid movements although the person remains asleep.

Most sleep is the deep, restful SWS. REM sleep occurs periodically, occupying about 25 percent of sleep time in the young adult. Episodes of REM normally recur about every 90 minutes and last 5 to 30 minutes. REM sleep is less restful than SWS and is usually associated with dreaming.  REM is essential to health. In laboratory tests using animals as the study group, deprivation of REM sleep can lead to death in a within a few weeks. In addition, a transitional stage of light sleep occurs at intervals throughout the sleep period.

Sleep was formerly attributed to decreased activity of brain systems that maintain wakefulness. More recent data indicate that sleep, like consciousness, is an active process. Sleep is controlled largely by nerve centers in the lower brain stem, where the base of the brain joins the spinal cord. Some of these nerve cells produce serotonin, a chemical messenger associated with sleep onset and with the regulation of SWS. Certain other nerve cells produce norepinephrine, which helps regulate REM sleep and facilitates arousal. The exact roles and interactions of these and other chemical messengers in orchestrating sleep patterns are not known. Significantly, however, alcohol consumption affects the function of these and other chemical messengers that appear to influence sleep.

Alcohol consumed at bedtime, after an initial stimulating effect, may decrease the time required to fall asleep. Because of alcohol's sedating effect, many people with insomnia consume alcohol to promote sleep. However, alcohol consumed within an hour of bedtime appears to disrupt the second half of the sleep period. The subject may sleep fitfully during the second half of sleep, awakening from dreams and returning to sleep with difficulty. With continued consumption just before bedtime, alcohol's sleep-inducing effect may decrease, while its disruptive effects continue or increase. This sleep disruption may lead to daytime fatigue and sleepiness. The elderly are at particular risk, because they achieve higher levels of alcohol in the blood and brain than do younger persons after consuming an equivalent dose. Bedtime alcohol consumption among older persons may lead to unsteadiness if walking is attempted during the night, with increased risk of falls and injuries.

Alcoholic beverages are often consumed in the late afternoon (e.g., at "happy hour" or with dinner) without further consumption before bedtime. Studies show that a moderate dose of alcohol consumed as much as 6 hours before bedtime can increase wakefulness during the second half of sleep. By the time this effect occurs, the dose of alcohol consumed earlier has already been eliminated from the body, suggesting a relatively long-lasting change in the body's mechanisms of sleep regulation.

The adverse effects of sleep deprivation are increased following alcohol consumption. Subjects administered low doses of alcohol following a night of reduced sleep perform poorly in a driving simulator, even with no alcohol left in the body. Reduced alertness may potentially increase alcohol's sedating effect in situations such as rotating sleep-wake schedules (e.g., shift work) and rapid travel across multiple time zones (i.e., jet lag). A person may not recognize the extent of sleep disturbance that occurs under these circumstances, increasing the danger that sleepiness and alcohol consumption will co-occur.

Normal aging is accompanied by a gradual decrease in SWS and an increase in nighttime wakefulness. People over 65 often awaken 20 times or more during the night, leading to sleep that is less restful and restorative. Age-related sleep deficiencies may encourage the use of alcohol to promote sleep, while increasing an older person's susceptibility to alcohol-related sleep disturbances. Potential sources of inconsistency among study results include different doses of alcohol employed and failure to screen out subjects with preexisting sleep disorders.

Sleep disturbances associated with alcoholism include increased time required to fall asleep, frequent awakenings, and a decrease in subjective sleep quality associated with daytime fatigue. Abrupt reduction of heavy drinking can trigger alcohol withdrawal syndrome, accompanied by pronounced insomnia with marked sleep fragmentation. Decreased SWS during withdrawal may reduce the amount of restful sleep. It has been suggested that increased REM may be related to the hallucinations that sometimes occur during withdrawal. In patients with severe withdrawal, sleep may consist almost entirely of brief periods of REM interrupted by numerous awakenings.

Despite some improvement after withdrawal subsides, sleep patterns may never return to normal in those with alcoholism, even after years of abstinence. Abstinent alcoholics tend to sleep poorly, with decreased amounts of SWS and increased nighttime wakefulness that could make sleep less restorative and contribute to daytime fatigue. Resumption of heavy drinking leads to increased SWS and decreased wakefulness. This apparent improvement in sleep continuity may promote relapse by contributing to the mistaken impression that alcohol consumption improves sleep. Nevertheless, as drinking continues, sleep patterns again become disrupted.

Blackouts

Blackouts are probably one of the most curious effects of drinking.  A blackout is an amnesia-like period often associated with heavy drinking.  It does not mean passing out or losing consciousness.  It does not mean psychologically blocking out the memory of an event or situation.  Many people assume it to be a sign of alcoholism.  Indeed, research does seem to suggest that blackouts more frequently occur with late stage alcoholism then at any other time in the drinking history.  However, a blackout can occur to anyone who drinks.  It is not always dependent on quantity of alcohol consumed, nor on the tolerance to alcohol.

The exact mechanism of a blackout is not fully under stood.  What we do know is that at some point, alcohol in the body causes the memory-processing activity of the brain to stop working for some period of time.  It may only last a few seconds or  for several hours, even after the alcohol has left the system.  When this occurs, the person continues to function normally, and all other aspects of the brain remain relatively intact.  Only the memory of that period of time is lost.  People walk, talk and act normally.  They may drive a car, fly a plane, or perform surgery without obvious impairment.

Many people may suffer a blackout and never know it.  It is only when confronted by another, or when they wake up and don’t know where they are or how they got there, that they realize a blackout has occurred.  Social drinkers who experience this effect are generally quite concerned and frightened by this.  They associate the episode with some specific pattern of drinking, and change the drinking pattern so as to not experience this again.  Alcoholics, on the other hand, assume that memory loss is a part of drink ing, and in spite of problems or concerns about such episodes, find that they are not able to change the occurrence, especially if they have no desire to stop drinking.

The Hangover

The Germans call it "katzenjammer" (wailing of cats), the Italians "stonato" (out of tune), the French "gueulu de boise" (woody mouth), the Norwegians "jeg har tommeermenn" (workmen in my head) and the Swedes "hont i haret" (pain in the roots of the hair).  While the names may be different, the feelings and effects are universal.  If you drink too much, you pay the price with the effects of a hangover.

The hangover - a familiar after effect of over-indulgence which causes fatigue combined with nausea, upset stomach, headache, thirst, depression, anxiety, general malaise, sensitivity to sound, and ill temper.  Hangovers aren’t much fun. They aren’t very well understood, either.

There is no simple explanation for what causes the hangover (other than having had too much to drink).  The symptoms are usually most severe many hours after drinking, when little or no alcohol remains in the body.

Theories for why the hangover occurs include the following: accumulation of acetaldehyde (a metabolite of ethanol), dehydration of the tissues, poisoning due to tissue deterioration, depletion of important enzyme systems needed to maintain routine functioning, an acute withdrawal response, and metabolism of the congeners in alcoholic beverages.

Dehydration does seem to have a significant role in creating the hangover effect.  When an individual drinks, the body loses fluid in two ways through alcohol’s diuretic action (diuretic - a drug or substance that increases the production of urine): (1) the water content, such as in beer, will increase the volume of urine, and (2) the alcohol depresses the center in the hypothalamus of the brain that controls release of a water-conservation hormone (antidiuretic hormone).  With less of this hormone, urine volume is further increased.  Thus, after drinking heavily, especially the highly concentrated forms of alcohol, the person is suffers from thirst.  However, this by itself does not explain all of the symptoms of hangover.

The type of alcoholic beverage you drink may influence the hangover that results.  Some people are more sensitive to particular congeners than others.  Congeners are natural products of the fermentation and preparation process, some of which are quite toxic.  Congeners make the various alcoholic beverages different in smell, taste, color, and, possibly, hangover potential.

Beer, with a 4% alcohol content, has only a 0.01% congener level, whereas wine has about 0.04%, and distilled spirits have congener levels of between 0.1% and 0.2%.  Gin, being a mixture of almost pure alcohol and water, has a congener content about the same as wine, whereas a truly pure mixture of alcohol and water (vodka) has the same congener level as beer.  Whiskey, scotch and rum have higher congener contents, thereby causing people who drink them to often suffer from the hangover effects.

Those who market alcohol beverages often take advantage of peoples suffering to promote their products.  One example deals with a new brand of Vodka being marketed in California at this time.  Called SKYY vodka, it is being marketed as an extra-pure form of vodka that will ease the hangover effects without sacrificing the taste.

Aging distilled spirits and wine does not decrease the level of congeners but, in fact, increases their level about threefold.  For example, some drinkers have no problem with white wine but an equal amount of some red wine will give them a hangover.  Also, there is little evidence that mixing different types of drinks per se causes a worse hangover.  What is more likely is that more than the usual amount of alcohol is consumed because of trying a variety of drinks.

A  study  titled "Experimental Induction of Hangover," provided support for  two factors that appear to contribute to the hangover syndrome: the higher your BAL, the more likely you are to have a hangover, and with the same BAL, bourbon drinkers were more likely (two out of three) than vodka drinkers (one out of three) to have a hangover.  This fits with the belief that some hangover symptoms are reactions to congeners.

Still other factors contribute to the trials and tribulations of the "morning after the night before."  The nausea and upset stomach typically experienced can most likely be attributed to the fact that alcohol is a gastric irritant.  The consumption of even moderate amounts causes local irritation of the mucosa covering the stomach.  It has been suggested that the accumulation of acetaldehyde, which is quite toxic even in small quantities, contributes to the nausea and headache.

The headache may also be a reaction to fatigue.  Fatigue sometimes results from a higher than normal level of activity while drinking.  Increased activity frequently accompanies a decrease in inhibitions, a readily available source of energy, and a high blood sugar level.  One of the effects of alcohol intake is to increase the blood sugar level for about an hour after ingestion.  This may be followed several hours later by a low blood sugar level and an increased feeling of fatigue.

How do you treat a hangover?  A common technique is to take a drink of the same alcoholic beverage that caused the hangover.  This is called "taking the hair of the dog that bit you" (from the old notion that the burnt hair of a dog is an antidote to its bite).  This might help the person who is physically dependent, the same way giving heroin to a heroin addict will ease the withdrawal symptoms.

This behavior is not unknown to moderate drinkers, either -  it may work to minimize symptoms, since it spreads them out over a longer period of time.  The "hair of the dog" method seems to work by depressing the centers of the brain that interpret pain or by relieving a withdrawal response in the central nervous system.  Also consider the psychological factors involved in having a hangover; distraction or focusing attention on something else may ease the effects.

Another folk remedy is to take an analgesic compound like an aspirin-caffeine combination before drinking.  Aspirin would help control headache; the caffeine may help counteract the depressant effect of the alcohol.  These ingredients would have no effect on the actual sobering-up process.  Products like aspirin, caffeine, and Alka-Seltzer can irritate the stomach lining to the point where the person may actually feel worse.

There is no evidence that the "surefire this’ll-fix-you-up" remedies are effective.  The only "surefire" remedy is the time proven method of an analgesic for the headache, rest, and time to recovery from the drinking episode.

 
Chronic Physical Effects of Alcoholism

There is no doubt as to the serious medical complications caused by alcoholism.  Alcoholism is currently listed as the third leading cause of death in our society.  Many alcohol related deaths go unreported, however, leading many professionals to believe that alcoholism is probably the number one killer.  For example, cirrhosis of the liver (most commonly associated with alcoholism) is one of the top ten leading cause of death by itself.  Often, if the cause of death is failure of a body organ or system, the role alcohol played is not considered.  If a person dies of a heart attack, yet drank alcoholically for 35 years of his or her life, the death is attributed to the heart attack, not the drinking.

As an irritant, alcohol has the potential of causing serious physical harm to any and all of the body systems.  Too often, though, medical and treatment professionals wait for the development of such physical symptoms to diagnose the problem of alcoholism.  Unfortunately, while alcoholism is a chronic and progressive illness, the early symptoms are generally behavioral and not physical.  The majority of medical problems typically appear in the late, chronic stage of the illness.  Waiting for physical signs to appear accounts for the high death rate associated with this problem.

The appearance of medical complications are secondary to the primary nature of alcoholism.  With proper evaluation and diagnosis of the problem, many alcoholics can avoid the more serious medical complications by becoming involved in a program of recovery.  The following table illustrates some of the problems both by general symptoms and the major body systems that are caused in the late stages of alcoholism.  While many of the terms and vocabulary used can be quite technical, it is important to know such terms and conditions in order to understand the nature of the long-term problems that alcohol can cause to the human body.

I. GENERAL APPEARANCE

A. Hand Tremor 

Part of alcohol withdrawal.  Can begin within hours after cessation of alcohol intake.  Mild expression of withdrawal.

B. Excitability, Irritability, Nervousness 

This stems from the sedative effect of alcohol being removed - the body rebounds from depression of the central nervous system to stimulation.  This may also be part of first stage alcohol withdrawal, resulting from the decrease of alcohol in the blood stream.  Also caused by lack of sleep; alcohol can cause a disturbance in REM sleep.  REM sleep is necessary for the body to physically and psychologically recover each and every day.

C. Jaundice  

The result of liver damage.  The yellow color comes from the pigment found in bile, a digestive juice made by the liver (the liver secretes 500 ml of bile/day).  Bile is handled improperly and thus begins to circulate in the bloodstream, causing the skin color to change to yellow

D. Rosacea, Seborrheic Dermatitis  (dry, red, itchy skin) 

Caused by a nutritional deficiency, especially B vitamin, as well as poor  personal hygiene

E. Parotid Swelling  

Alcohol affects salivary glands which leads to an increased stickiness of saliva, causing blockage of salivary ducts and a mumps-like appearance due to swelling of parotid gland.

F. Finger Clubbing  

Referred to as "Drumstick" disease.  Tips of fingers swell, causing a puffiness that covers the fingernails.  The cause is alcohol cardiomyopathy, resulting in poor circulation to extremities.

G. Rhinophyma ("Drinker’s Nose")   

A painless increase in nasal sweat glands which causes an increase in the size of the lower part of the nose.

II. GASTROINTESTINAL TRACT

A. Dyspepsia 

A general feeling of discomfort after eating.  Due to imperfect digestion (not an illness itself, but a symptom of one).  A sign of gastritis, which is inflammation of the stomach and is the most common GI ailment stemming from alcoholism.

B.Nausea & Vomiting   

Vomiting has been referred to as the body’s "housecleaning" - when the body is unable to process food in the stomach, the system tends to force its removal.  Also a sign of gastritis.

C. Recurrent Diarrhea  

Alcohol changes the motility of the intestinal tract.  The first 16 to 20 inches of the small intestine are impacted.  Once the stomach deposits chyme (gruel-like material produced by gastric digestion of food) in the small intestine, the body should begin to absorb the necessary food stuff for use and storage.  Alcohol in the blood stream inhibits the small intestine from absorbing certain minerals and nutrients from the chyme, causing it to function improperly.  Beyond that point, alcohol causes an increase in the rate of propulsion of food through the small intestine.  This results in malabsorption of food in the remainder of the small intestine.

D. Recurrent Abdominal Pain    

Alcohol causes inflammation of stomach and colon.

E. Acute & Chronic Pancreatitis

About 50% of all cases of pancreatitis are alcohol related.  Alcohol has a direct toxic effect on the pancreas, causing changes in the secretions of the pancreas.  Increased secretion of digestive juices can produce pancreatic irritation and damage.  Most researchers believe that the disease-causing mechanism is the alcohol-induced increase in protein concentration in pancreatic juice - precipitates and clogs the ducts of the organ.

1. Acute pancreatitis  

Most often seen in men, 26-65 years of age, with a minimum of 5-10 years of active drinking.  

Symptoms: Constant, severe epigastric pain which may radiate to the back; nausea and vomiting.  Usually begins one or two days after heavy use.

2. Chronic pancreatitis 

Gradual, subtle onset with severe pain

F. Hypoglycemia & Hyperglycemia

Alcohol causes rapid change in blood sugar - with the increase of alcohol in the blood stream, the pancreas responds with an increased output of insulin that leads to a decrease of blood sugar.  This decrease causes the liver to produce glycogen to replace the lost blood sugar, generally resulting in an increase in blood sugar.

G. Gastrointestinal Bleeding

Prime cause is the destruction of the stomach lining due to an increase in stomach acids.  This may also result in ulcers, causing additional bleeding.

H. Liver   

Metabolizing alcohol is always a priority for the liver (approximately 1/2 ounce of ETOH per hour).  The toxic effects of alcohol can cause several problems, even with proper nutrition:

1. Alcohol fatty liver - Liver overproduces glycogen to compensate for lost sugar in bloodstream; Metabolism of alcohol leads to accumulation of free fatty acids which leads to an increased concentration of fat in the liver.

Signs and Symptoms: liver enlargement; changes in liver enzymes (detectable on a routine lab examination).

2. Alcoholic hepatitis - Syndrome of necrosis (cell death) and inflammation may occur rapid or over a long period of time. 

Signs and Symptoms: Hepatomegaly (enlarged liver), jaundice, liver pain, fever, leukocytosis (increased WBC’s), ascities - cirrhosis may result from this condition.

3. Cirrhosis - Advanced necrosis with resultant scarring associated with formation of nodules - generally irreversible to 100%, though liver can reproduce tissues to restore a greater level of health with abstinence.

4. Ascites - the accumulation of fluid in the abdominal cavity.  Due to an increase in the size of the liver and compression of the liver on blood vessels, resulting in the leakage of fluid from the liver into the abdominal cavity.  A tell-tale sign of this condition is the wave-like action of the abdominal cavity when tapped, as well as the skin tone appearing paper thin and glistening.

III. CARDIOVASCULAR

A. Palpitations

Irregularity in heartbeat occurs both in patients with alcohol related diseases and in other individuals during alcohol intoxication.

B. Cardiomyopathy

Otherwise known as heart disease - one out of thirty-six alcoholics develop this condition

Signs and symptoms: Chronic shortness of breath and signs of congestive heart failure.

C. Anemia  

Alcohol inhibits the bone marrow’s ability to use iron in making hemoglobin, the oxygen-carrying part of blood.  B12 not taken in or poorly stored which leads to immature RBC’s or WBC’s.  Incomplete production of red blood cells; defect in RBC maturation leads to macrocytosis (enlargement) and increased Mean Corpuscular Volume (MCV).  Bone marrow is sedated by alcohol - unable to produce as many RBC’s or WBC’s.  Three drinks destroy as many platelets as you can make in one day.  This leads to bruising and high clotting times.

D. Dilation of Blood Vessels 

Alcohol causes peripheral blood vessels to dilate and leads to a loss of body heat.  Many people drink straight spirits in cold weather to increase warmth when in reality alcohol causes the body to lose its internal heat.  Such an effect can lead to frostbite.  Body temperature regulate is also impaired.

IV. RESPIRATORY SYSTEMS

A. Chronic Obstructive  Airways Disease (COAD)  

Related to loss of air capacity of lungs and loss of elasticity - alcohol contributes to this. Alcohol has a direct toxic effect on lung tissue and kills the alveoli (air sacs) in the lungs.

B. Recurrent Chest Infection and Pneumonia 

Alcohol dries lung tissue and bronchi and causes them to become irritated and inflamed and susceptible to infection.  Alcoholics have decreased ability to fight infections due to suppression of the immune system (decreased WBC’s and machrophage).  Alcohol has a numbing effect and makes it hard to get secretions out of the lung.

V. CENTRAL NERVOUS SYSTEM

A. Impact on Neurons (Brain Cells) 

It has long been estimated that each drink of alcohol kills approximately 10,000 neurons.  Recent scientific findings now suggest that the cells may not actually die, but be "disconnected" as a result of drinking and not be able to perform their tasks.  Either way, neurons are specialized cells that do not reproduce.  Alcohol thickens the conductive material between brain cells, slowing down electrical impulses -  cell has trouble referring impulses from one cell to the next.  Damage to the brain caused by alcohol particularly affects the frontal lobes, making a person unable to give up behavior patterns which are harmful.  He is unable to make long-range plans and use intellect for decision making.  May take up to two years for all functions to return, if they do at all.

B. Short-Term Memory Impairment  

Alcohol interferes with brain functioning and can cause loss of memory, particularly for recent events.  Chronic drinking for ten days or more leads to impaired protein synthesis which leads to brain cell damage.  Memory tends to return to normal after a period of abstinence from alcohol.

C. Blackouts 

Short-term memory loss is like a period of amnesia.  Quantity of alcohol consumed seems to have no direct relationship to frequency of blackouts.

D. Seizures  

Tend to occur from 7-48 hours after cessation of drinking.  Commonly of the grand mal type, but can also be petit mal seizures: 1-3% of all chronic abusers will have seizures.  Chronic alcoholism results in an abnormally elevated seizure threshold followed by a period of lowered seizure threshold; this, plus decreased blood alcohol level, altered electrolytes, and decreased blood glucose, can lead to seizures.

E. Peripheral Neuropathy (nerve disease)

Vitamin B deficiency, especially thiamine, leads to peripheral neuropathy (tingling and numbness in hands and feet).  Vitamin B deficiency leads to impaired production of the enzymes needed for maintaining the covering of the nerve cells.  This loss causes destruction of nerve cells which results in tingling and numbness, as well as muscle weakness.

F. Ataxia (Loss of Balance)  

Results of peripheral neuropathy (nerve damage)- loss of  balance and coordination occurs which results in the characteristic of the "wide based gait" in order to keep balance.  Late onset, generally develops over months of use, a result of vitamin B deficiency

G. Insomnia, Nightmares  

Large amount of alcohol disturbs REM sleep.  Brain forces REM sleep, resulting in dreams that are intense, nightmare in quality.

H. Hallucinations

Basically means that the brain is so sick and irritable that it sees, hears and feels things that aren’t there.  Agitated condition breaks through because alcohol has raised agitation so high that no amount of current sedation can reduce it

I. Delirium Tremens   

Late stage withdrawal phenomenon.  Sensory input plus motor output has become tremendous, and alcoholic is unable to stop moving.

All four stages of withdrawal present:

1.     Hyperarousal,

2.     Hallucinations,

3.     Convulsive seizures,

4.     Delirium Tremens.

Observable features include restlessness, increased blood pressure (especially diastolic reading), increased pulse and low-grade temperature.

J. Wernicke Syndrome, Korsakoff Psychosis

Both caused by nutritional deficiencies, especially the loss of thiamine, plus toxic effects of alcohol on nerve tissue

1. Wernicke Syndrome - Injury to the brainstem and areas near the third and  fourth ventricle of the brain - results in:

Diplopia (double-vision),

Hyperactivity and delirium.  Responds rapidly to vitamins - this condition is reversible with vitamin replacement.

Signs and symptoms: Confused, delirious and  apprehensive.  Characteristic dysfunction: Nystagmus (eyes do not track together), ataxia.

2. Korsakoff Psychosis - Chronic brain damage caused by thiamine deficiency. Sludging of dead red blood cell components in small capillaries results in cell and tissue destruction due to hyposia (lack of oxygen); Damage occurs to the cerebral cortex and peripheral nerve tissue.

Signs and symptoms: Severe disorientation, delirium, memory loss and confabulation (hallmark sign - due to memory loss, the individual generally makes up elaborate stories to cover the loss or to fill in holes in the memory).

VII. MUSKULOSKELETAL

A. Muscle Atrophy   

Wasting of muscles due to improper nourishment to muscle tissue - can result in acute pain in upper arms, shoulders and pelvic area.

B. Alcoholic Myopathy

Long-term alcohol use produces increased levels of enzyme serum creatine and phosphokinase, resulting in muscle cramps, weakness.

Acute symptoms:

-        Sudden onset of weakness - may be acute pain in skeletal muscles;

-        Follows drinking bout;

-        Involves proximal muscles, extremities, pelvic and shoulder girdle, muscles of the thoracic cage.

Chronic symptoms:

-        Muscle weakness involving muscle groups as listed above, but without pain or tenderness;

-        Enzymes on blood test are not elevated, making it difficult to diagnose the problem, especially if the person denies drinking.

C. Nephritis (Inflammation of the Kidneys)

Kidneys fail to operate efficiently, leaking out blood cells, albumin, etc.  May result in a red color to the urine.

D. Amenorrhea (Loss of Menstruation) 

Alcohol interferes with the absorption of calcium which is needed for the ovaries to work efficiently.  Use of alcohol may cause women to skip menstrual periods.  Alcohol interferes with the absorption of calcium which is needed for the ovaries to work efficiently.  Not as much known about women’s disorders in general since the increase of women in treatment is relatively new, and research is lacking.

E. Impotence 

Use of alcohol decreases testosterone, increases estrogen in the male (liver fails to work properly to assist in sex hormone levels).  Results in feminization features (loss of facial hair, possible breast enlargement).  Alcohol also has a direct toxic effect on testes and leads to a decreased plasma testosterone, decreased fertility and atrophic (shrunken) testes.

VIII. GENITOURINARY

A. Polyuria (increased urine flow)

Alcohol has a diuretic effect while blood alcohol increases.  Diuresis caused by supression of the release of anti-diuretic hormones from the pituitary gland. ADH allows kidneys to filter water from urine, reabsorbing water and moving urine to bladder for disposal.  With loss of filtering ability, the kidneys pass the water with the urine, generally causing an increase urge to void.  Extent of diuresis is dependent on a rising blood alcohol condition and the rate of rise.  As BAC becomes steady or falls, effect is reversed and the body actually can cause the retention of urine and exacerbation of urinary tract infections and/or prostatitis.

B. Electrolyte Imbalance

Excretion of sodium and chloride is decreased due to drinking.  Alcohol causes the loss of magnesium which leads to restlessness, mental slowing.

IX. LAB VALUES TO OBSERVE

Many of the problems and conditions discussed above may not materialize until many years of problem drinking has existed.  Waiting for physical conditions to occur before diagnosing the problem of alcoholism has lead to the extraordinarily high death rate.  Yet current research suggests that various indicators do exist that signal the likelihood of alcoholism.  A standard blood test can give an indication of the internal workings of the human body, as well as a look at how alcohol might be causing disruption to the normally healthy systems. 

Research suggests that by looking for the following values on a blood test, an effective diagnosis might be reached well in advance of physical tissue destruction:

1.     Increased Uric Acid

2.     Increased Triglycerides

3.     Increased GGT

4.     Increased MCV (mean corpuscular volume)(due to cell being deficient in B12 and folic acid - cell has to work harder and grows larger) 

5.     Increased Alkaline Phosphatose (true in cases of chronic alcoholism

Studies indicate that when the combination of these values are found, it is likely that alcoholism is the cause in 95% of the cases.

Additional physical testing can also pinpoint the onset of potential problems related to alcoholism.  It is important for the chemical dependency counselor to have some familiarity with such tests and findings, especially because of their value to the intervention process.  Coursework is available at most colleges and universities that will provide this information. Also, the best source of information may come from the medical staff of your treatment program.  Do not hesitate to ask questions and learn more about these types of testing.

Alcoholism

One of the greatest health problems in society today is the problem of alcoholism.  It is currently the third leading cause of death in our society, behind cancer and heart disease.  It is the most extreme form of problem drinking in our society today.  Yet many people do not understand the problem, or don’t understand the term.

Many people define alcoholism in relationship with how they themselves drink.  If I only drink on weekends, then an alcoholic is someone who drinks every day.  If I only drink beer, then an alcoholic is someone who drinks hard liquor.  If I only drink after noon, than an alcoholic is someone who drinks in the morning.  If I only drink six drinks at a sitting, then an alcoholic drinks more.

Part of the problem in understanding this illness is that many professional groups fail to define it adequately.  The American Psychiatric Association uses the following definition:

Alcoholism: this category is for patients whose alcohol intake is great enough to damage their physical health, or their personal or social functioning, or when it has become a prerequisite to normal functioning.

The World Health Organization uses the following definition:

Any form of drinking which in extent goes beyond the tradition and customary dietary use, or the ordinary compliance with the social drinking customs of the community concerned, irrespective of etiological factors leading to such behavior, and irrespective also of the extent to which such etiological factors are dependent upon heredity, constitution, or acquired physiopathological and metabolic influences.

Alcoholics Anonymous, while having no official definition, generally cites the concept of Dr. William Silkworth, a friend of AA:

An obsession of the mind and an allergy of the body.  The obsession or compulsion guarantees that the sufferer will drink against his own will and interest.  The allergy guarantees that the sufferer will either die or go insane.  An alcoholic is a person who cannot predict with accuracy what will happen when he takes a drink.

As previously noted, the American Medical Association in 1956 defined alcoholism as follows:

Alcoholism is an illness characterized by preoccupation with alcohol; by loss of control over its consumption, such as to usually lead to intoxication or drinking done by chronicity; by progression and by tendency to relapse.  It is typically associated with physical disability and impaired emotion, occupational and/or social adjustments as a direct consequence of persistent and effective use.

Because of the reliance we have in using the AMA to define alcoholism as a disease, yet the difficulty which exists in using this definition, a 23-member multidisciplinary committee of the National Council on Alcoholism and Drug Dependence and the American Society of Addiction Medicine recently conducted a 2-year study of the definition of alcoholism in light of current knowledge and concepts.  As a result, a new definition has been made which is:

   1) scientifically valid,

   2) clinically useful, and

   3) understandable by the general public.

The following is the new definition, as published in The Journal of the American Medical Association, August 26, 1992 (reprinted by permission):

Alcoholism is a primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations.  The disease is often progressive and fatal.  It is characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking, most notably denial.  Each of these symptoms may be continuous or periodic.

"Primary" refers to the nature of alcoholism as a disease entity in addition to and separate from other pathophysiologic states that may be associated with it.  It suggests that as an addiction, alcoholism is not a symptom of an underlying disease state.

"Disease" means an involuntary disability.  Use of the term involuntary in defining disease is descriptive of this state as a discrete entity that is not deliberately pursued.  It does not suggest passivity in the recovery process.  Similarly, use of this term does not imply the abrogation of responsibility in the legal sense.  Disease represents the sum of the abnormal phenomena displayed by the group if individuals.  These phenomena are associated with a specified common set of characteristics by which certain individuals differ from the norm and which places them at a disadvantage.

"Often progressive and fatal" means that the disease persists over time and that physical, emotional, and social changes are often cumulative and may progress as drinking continues.  Alcoholism causes premature death through overdose; through organic complications involving the brain, liver, heart, and other organs; and by contributing to suicide, homicide, motor vehicle accidents, and other traumatic events.