How to win the struggle with alcoholism

A few years ago, I attended the funeral of a close family relative who had succumbed to alcoholism. Friends and family members related their shock and surprise in being unable to reconcile their experience of him as a personable, intelligent young man with the darker side of him which was fighting a losing battle with addiction. A Jekyll and Hyde personality, they called it. Also surprising was the attendance of some of his relatives who were drunk at the funeral. This appeared disrespectful, but it was pointed out that they too were struggling with alcoholism, and drinking was a mechanism of coping with the stress of his loss. I began to suspect that the condition likely runs in families, particularly after many persons shared their own experiences of dealing with the alcoholic in their families. 

          People with Alcohol Use Disorder (AUD), the medical term for alcoholism, have an impaired ability to stop or control alcohol use despite adverse social, occupational, or health consequences. Worldwide, alcoholism causes three million deaths every year, is responsible for 5.1% of the global burden of disease, and is causally associated with more than 200 diseases, including the heart, liver, and brain, and cancer. A significant proportion of these deaths and injuries are from intentional and unintentional injuries. The disease of addiction does not respect social class, race, or national boundaries. It occurs in rich and poor, black and white, and all skin colors in between. Its prevalence in any given society depends on economic development, culture, availability, and alcohol regulation policy. Even in societies where alcohol is shunned, addiction takes the form tobacco, drugs, and gambling overuse. Alcohol is one of the most ancient and widely used drugs. As a social lubricant, it has played a role in social ceremonies associated with births, marriages, deaths, medicine, magic, and war and peace. The 5th century historian, Herodotus, claimed that ancient Persians debated important social matters with and without the influence of alcohol and adopted those conclusions which were similar in both circumstances. In matters of sex, Shakespeare wrote that ‘it provokes the desire, but takes away the performance.’ Alcohol consumption is also responsible for a host of unwanted effects such as crime, indulging in unsafe sex, and dating violence. 

Since the past few decades, alcoholism has been increasingly recognised as a multifactorial condition with risk factors ranging from age at first consumption, amount and speed of consumption, inheritance of the addiction gene, and mental health conditions and trauma. Familial studies have noted an interplay between genes and the environment with 60% heritable factors and parents’ drinking patterns influencing the risk of AUD development in children. It is not well known that, in certain countries, children were encouraged to drink fermented low-alcohol beer when the water supply was unsafe. Those who did so likely lessened their chances of dying from childhood diarrhea but may have increased their risk of becoming alcoholics if the alcohol content in beer varied significantly. Mental conditions such as depression, post-traumatic stress disorder, attention deficit hyperactivity disorder, and childhood trauma increase the risk of developing alcoholism, as it is an easily accessible drug to suppress and medicate the pain of living with such conditions. A new large-scale study on alcohol shows that even light to moderate consumption is harmful to the brain. Going from one or two to two or three drinks per day reduces brain volume. 

Recognition of the above factors have been instrumental in classifying alcoholism as a brain condition or disease. While there is still considerable social stigma and victim blaming associated with its use, calling it a brain condition with specific treatment strategies offers a ray of hope for the alcoholic and their families. In my encounters with alcoholics in my medical career and in family situations, I have come to understand that the brain of the alcoholic is wired differently from others. Alcohol can cause lasting changes in the brain, which makes patients vulnerable to relapse. Relapses occur after a period of alcohol abstinence and increase with exposure to people and places associated with past drinking. They are particularly painful to the alcoholic and their families as the alcoholic is transformed in a matter of hours from normal to at times unacceptable  behaviour with its consequential effects.  The good news is that a variety of evidence-based treatment approaches are now available. One caveat is that the success of treatment is dependent on the willingness of the patient to recognise the problem, seek help, and follow the treatment programme. Enforced admission into rehabilitation programmes by concerned family members serves as only a temporary solution in many cases and this kind of admission is not entertained by many of the better programmes. The evidence-based treatment strategies include behavioural therapy and medication. The goals of behavioural therapy include stress and emotional counseling, building a strong social support system, setting reachable goals, and avoidance of triggers that might cause relapse. Medications are used manage more chronic conditions. Because they may not work for all patients, research is ongoing to develop a menu of drug treatments which can be tailored to the individual. Treatment for this complex multifactorial disease needs to be adapted to local socio-economic and cultural conditions. In India, the NGO Sangath is working on a research agenda focused on addictions and mental health in low-resource settings. Their community outreach programmes comprise collaboration between lay counsellors and primary care physicians without the need for expensive hospital admission. Mutual self-help groups like Alcoholics Anonymous (for the alcoholic) and Al-Anon (for families of alcoholics) play a vital role in this process. 

Because of the lifelong nature of alcoholism and addiction, patients and their families must quickly recognise the condition, seek help, and follow the treatment programme. However severe and hopeless the condition may appear in the beginning, there is always hope for the alcoholic and their families for help with this devastating disease.