LEVELS OF USE
The effects of any drug depend on the dosage. The same substance can be a poison, a powerful prescription medicine, or an over-the-counter mild medication depending on the dose and frequency of use. Alcohol is no exception; it can be used in low, moderate, or high doses and it can be used infrequently or often. As with other psychoactive drugs, there are escalating patterns of use.
Abstention (no use)
"My brother experimented with Puerto Rican rum on New Year's Eve when he was 15. He threw up on me on the way to the toilet. That took care of his drinking for five years and mine forever."
Experimentation (use for curiosity with no subsequent drug-seeking behavior)
"The first time I tried beer . . . well when you're a little boy, your dad says, 'Go get me a beer.' You pop it open for him and they let you take a sip every once in a while as long as mom's not looking. It tasted good. When you're 10 or 12, you don't really know what alcohol is, you just experience it every once in a while."
Social/Recreational Use (sporadic infrequent drug seeking with no established pattern)
"We know which dorm has the drinkers, so when we feel like a bit of a party and a few drinks, that's where we go.
20-year-old college sophomore
Habituation (established pattern of use with no major negative consequences)
"I think the pleasure left. The maintenance thing was . . . now I didn't know how to live any other way. This was the only way I knew how to have fun. This was the only way I knew how to feel better. But it didn't work and it took me awhile to realize that it had become a habit."
36-year-old recovering alcoholic
Abuse (continued use despite negative consequences)
"I always got Bs, and then my grades dropped down to Ds, and then I started failing my classes, and I skipped school, and I got suspended all the time for that when I got caught. I'd skip school and I'd go get high or we'd just skip it because we were always high and we thought it was boring."
15-year-old high school dropout in treatment
Addiction (compulsion to use, inability to stop use, major life dysfunction with continued use)
"I would have the shakes, just really sick. I mean my body could not take alcohol at all. I would be sick in the morning like for days . . . and hard to go to work and hard to take care of my children, hard to do my daily chores. It took me a long time to get well in the morning until I realized there was a magical cure. I could start drinking bloody Mary's or something that wouldn't upset my stomach and I would be all right again. But then what would happen was once I started I couldn't stop, so I was back on the merry-go-round again."
33-year-old recovering alcoholic
LOW- TO MODERATE-DOSE EPISODES
There are no conclusive studies that drinking small amounts of alcohol, even over an extended period, has negative health consequences for men, nor are there conclusive indications that infrequent mild intoxication episodes have no lasting adverse health consequences for most male drinkers. While this statement may be physiologically correct, alcohol's disinhibiting effect at low doses can result in automobile crashes and legal problems, along with unwanted pregnancies and sexually transmitted diseases, including HIV/AIDS, from high-risk sexual activity. This not withstanding, studies have shown that drinking two drinks of alcohol, especially two glasses of wine or less each day, has some positive health benefits for men including decreased coronary artery disease (NIAAA, 1999). The situation for women, except in relationship to heart benefits, is quite the opposite. Several studies demonstrate that even low levels of drinking in women with a certain genetic susceptibility can result in major health consequences such as an increase in breast cancer (Thun, Peto, Lopez, et al., 1997; Zhang, Schatzkin, Kreger, et al., 1998). Further, studies demonstrate that women who drink are at higher risk to develop liver cirrhosis, pregnancy problems, and even AIDS when they drink moderate amounts of alcohol (NIAAA, 1997; Maher, 1997).
In addition low-level alcohol use is generally not safe for people who
- are pregnant;
- have certain preexisting physical or mental health problems that are aggravated by alcohol;
- are allergic to alcohol, nitrosamines, or other congeners and additives;
- have a high genetic/environmental susceptibility to addiction;
Sometimes it is difficult to define moderate drinking because each person has a different definition. We will define moderate drinking as drinking that doesn't cause problems for the drinker or for those around him or her (Alcohol Alert, 1992). However, drinkers begin to have pathological consequences to alcohol when they have more than two drinks per day in men and zero to one drink per day in women. Severe effects and long-term health and social consequences usually result from high-dose use episodes and frequent high-dose or chronic use.
Low- to Moderate-Dose Use, Physical Efffects:
Therapeutic Uses. Alcohol is used as a solvent for other medications since it is water- and lipid-soluble. It is used as a topical disinfectant. Isopropyl alcohol is used as a body rub to reduce fever since it evaporates so quickly. Ethanol has been used as a pain reliever for certain nerve-related pain; systemically it is used to treat methanol and ethylene glycol poisoning; it is occasionally used to prevent premature labor (Woodward, 1998).
Desired Effects.Some people who drink alcoholic beverages think that they taste good, quench the thirst, and relax one's muscle tension. Consumed in low doses before meals, alcoholic beverages activate gastric juices, improve stomach motility, and stimulate the appetite. They produce a feeling of warmth since vessels dilate and blood flow to subcutaneous tissues increases (Woodward, 1998). Alcohol has a slight dehydrating effect on the body, so when people add caffeinated beverages (which act as diuretics) to their drinking, they can overheat on a hot day.
Light to moderate use of alcohol (up to one drink a day for women and two drinks a day for men) has been shown to reduce the incidence of heart disease (Boffetta & Garfinkel, 1990). Whether the cause is the increase in high-density lipoproteins, particularly HDL3, a different interaction with lipoproteins, or simply the decrease in tension that a drink can induce, light to moderate use reduces plaque formation. The doses must be low enough not to cause liver damage, induce other adverse health effects, or trigger heavier drinking. Of course any beneficial effects may also be obtained through exercise, low-fat diets, stress-reduction techniques, and an aspirin a day. (On autopsy many "winos" have clean blood vessels and badly damaged livers, hearts, and brains.) The American Heart Association Guidelines on Alcohol Consumption says that one to two drinks per day for men and one drink per day for women seems to lower the health risk but because of the dangers involved if the drinking increases, any recommendation concerning alcohol should be in consultation with a physician (AHA, 1996).
Researchers at Columbia University found in a study of 677 stroke victims that those who have one or two drinks a day have a lower risk of strokes because alcohol keeps blood platelets from clumping (Sacco, Elkind, Boden-Albala, et al., 1999). But again since heavy drinking actually increases the risk of stroke, and even moderate drinking has unwanted side effects, and since no benefit is shown in recommending moderate drinking to abstainers, using alcohol as a stroke-preventive measure should only be done in consultation with a physician.
Sleep. Alcohol is often used by people to get to sleep particularly if anxiety is causing insomnia. In fact alcohol does decrease the time it takes to fall asleep but it also seems to disturb the second half of the sleep period especially if consumed within an hour of bedtime (Landolt et al., 1996; Vitiello, 1997). Drinking also seems to have an effect on obstructive-sleep apnea, a disorder where the upper breathing passage (pharynx) narrows or closes during sleep causing the person to come awake, often a number of times during a sleep period, thus leading to fatigue. Those with alcoholism have an increased risk of sleep apnea and those with the condition seem to aggravate their disease by drinking (Miller, et al., 1988; Dawson, Bigby, Poceta, & Mitler, 1993).
Low- to Moderate-Dose Use: Psychological Effects
The effects of alcohol, particularly the physical effects (as with most psychoactive drugs), are dependent on the amount and frequency taken. The mental and emotional effects are also conditioned by the setting in which the drug is used along with the mood and general psychological makeup of the user (Peele, 1995). In general, alcohol affects people psychologically by lowering inhibitions, increasing self-confidence, and promoting sociability. It calms, relaxes, sedates, and reduces tension. But for someone who is already lonely, depressed, suicidal, or angry, the depressant and disinhibiting effects of alcohol can deepen these emotions, so for some drinkers that means sociability and talkativeness and for others, verbal or physical aggressiveness and even violence.
"I started out drinking when I was about 15 out of peer pressure but it made me forget about everything. It felt like a whole new way of life. I was happy; I was gregarious; I was outgoing . . . more extroverted . . . I guess I love dancing and I thought I was Ginger Rogers in that I thought I could do anything."
42-year-old recovering alcoholic
Disinhibition & GABA.
The blocking of inhibitions is caused by alcohol's action on the higher centers of the brain's cortex, particularly that part of the brain that controls reasoning and judgment. Alcohol first affects the cortex and then it acts on the lower centers of the limbic system that rule mood and emotion.
Alcohol's psychological effects stem from the drug's interaction with the brain's neurotransmitters, particularly met-enkephalin (which can reduce pain), serotonin (scarcity causes depression and excess causes anxiety), dopamine (which can give a surge of pleasure), and particularly gamma amino butyric acid (GABA). GABA is the major inhibitory neurotransmitter in the brain, so by activating the inhibiting effects of GABA, alcohol lowers inhibitions and slows down all of the brain processes (Valenzuela & Harris, 1997).
"The pleasure then that I liked was just getting high, just feeling like other people feel. Like I don't know if you call this, 'feeling human.' I guess so 'cause you're high and you fit in with everyone else."
36-year-old recovering polydrug abuser
Other neurotransmitters affected by alcohol are endorphins, corticotropin, and acetylcholine.
Low- to Moderate-Dose Use:
More than any other psychoactive drug, alcohol has insinuated itself in the lore, culture, and mythology of sexual and romantic behavior: a beer "kegger" party to look for a date, a rum and coke before sex, or champagne to celebrate an anniversary. Almost half of a group of 90,000 college students at a number of two and four-year institutions believed that alcohol facilitates sexual opportunities (Presley et al., 1997). Whether it does so because of actual psychological and physiological changes or because of expectations that it will is still open to question.
"It's no mystery why guys in college fraternities, many of whom don't have all that much money, still come up with plenty of money to have outrageous amounts of alcohol and let any woman in for free. The whole point is they're setting up an environment whereby people are going to get more drunk. Women's inhibitions and a guy's inhibitions are going to get lowered."
23-year-old college counselor
The acceptability of using alcohol extends to high school students. A survey done for the U.S. Surgeon General found that 18% of females and 39% of males say it is acceptable for a boy to force sex if the girl is stoned or drunk (Surgeon General, 1992).
"It doesn't matter if alcohol was involved in the situation. He raped me. It doesn't matter. There's more attention paid to the fact that there was alcohol involved than the fact that a woman was assaulted . . . and that her life changed and that all of these things happened as a result of that. Alcohol's involved in almost every social situation but it doesn't mean that we recognize it or validate it."
22-year-old female college senior
Alcohol's physical effects on sexual functioning are closely related to blood alcohol levels. In low doses alcohol usually increases desire in males and females, usually heightening the intensity of orgasm in females and slightly decreasing erectile ability and delaying ejaculation in males (Blume, 1997; Wilson & Lawson, 1976). Alcohol dilates peripheral blood vessels making it difficult to maintain an erection.
High-Dose Use: Physical Effects of Intoxication
Intoxication is a combination of both psychological mood, expectation, and past drinking experience as well as the physiological changes caused by elevated blood alcohol levels. In most states a person is legally intoxicated when the BAC reaches .10. However, the effects of legal intoxication can be partially masked by experienced drinkers. Experiments have indicated that there is a so-called expectancy effect, such that someone who has not consumed alcoholic beverages but thinks he or she has can exhibit signs of intoxication.
Binge drinking is defined as consuming five or more drinks in a row at one sitting for males and four or more in a row for girls. About 43% of college students say they are binge drinkers while 23% say they binge frequently (Wechsler, Lee, Kuo, & Lee, 2000). In the general population by comparison, only 15.6% binge while 5.9% admit to heavy use (heavy drinking is defined as five or more drinks in one sitting at least five times a month). As with college students, any person who binge drinks is more likely to have hangovers, experience injuries, damage property, and have trouble with authorities (Presely et al., 1997).
However after enough drinks are consumed, expectation, setting, and the mood of the drinker cease to have a strong influence and the depressant effects of the alcohol take over (depending on the tolerance of the drinker). As more alcohol is drunk, blood pressure is lowered, motor reflexes are slowed, digestion and absorption of nutrients becomes poor, body heat is lost as blood vessels dilate, and sexual performance is diminished. In fact every system in the body is strongly affected. Slurred speech, staggering, loss of balance, and mental confusion are all signs of an increased state of intoxication.
High-Dose Use: Alcohol Poisoning (overdose)
If truly large amounts of alcohol are drunk too quickly, severe alcohol poisoning occurs and depression of the various systems can lead to unconsciousness (passing out), coma, and death. Some clinicians use a BAC level of .40 as the threshold for alcohol poisoning.
However, even blood alcohol concentration levels of .02 or greater can result in severely depressed respiration and vomiting while semiconscious. The vomit can be aspirated or swallowed, blocking air passages to the lung, resulting in asphyxiation and death. This can also cause infections in the lungs.
High-Dose Use: Mental & Emotional Effects
"I remember being beat up physically and being emotionally abused and drinking a gallon of wine and feeling like I just wanted to be out of it. And for me, that was the way to deal with the pain. I think women tend to do those things; either they'll take drugs with the perpetrator to have some kind of relationship or after they've been beat up, use alcohol or drugs as a way of not to deal with the pain."
43-year-old ex-wife of abuser
Alcohol depresses other functions of the central and peripheral nervous systems. Initial relaxation and lowered inhibitions at low doses often
become mental confusion, mood swings, loss of judgment, and emotional turbulence at higher doses. At a BAC of .05, the thinking and judgment of a drinker become impaired. At a BAC concentration of .10, the level designating legal intoxication in many states, a drinker may demonstrate slurred speech and beyond that level, progressive mental confusion and loss of emotional control. Heavy alcohol consumption before sleep, as with light to moderate consumption, may also interfere with the REM (rapid eye movement) or dreaming sleep essential to feeling fully rested. Chronic alcoholics may suffer from fatigue during the day and insomnia at night, as well as nightmares, bed wetting, and snoring.
Figure 5-4. As consumption increases, the amount of alcohol absorbed increases and therefore the effects increase but at different rates depending on the physical and mental makeup of the drinker.
High-Dose Use: Blackouts
Some alcoholics suffer blackouts during heavy drinking bouts. During blackouts, a person is awake and conscious and seems to be acting normally but afterwards cannot recall anything that was said or done. Sometimes even a small amount of alcohol may trigger a blackout. Blackouts, which are caused by an alcohol-induced electrochemical disruption of the brain, are often early indications of alcoholism. They are different from passing out or loss of consciousness during a drinking episode since any drinker can pass out from too much alcohol. A drinker can also have a brownout, which is a partial recall of events. A possible indicator of this phenomena and therefore a marker for alcoholism is the reduced amplitude of an electroencephalograph (EEG) event-related potential (ERP) brain wave called the "P3 or P300 wave." This wave demonstrates cognition, decision-making, and processing of short-term memory. This reduced ERP is found in alcoholics and their young sons but not in social drinkers (Begleiter, 1980; Blum, Brauerman, Cull, et al., 2000).
"With alcohol I was out of control because I would drink to the point where I didn't know what I was doing, which made it easier for the man to do whatever he wanted and my not realizing it until the next day or the next morning when I woke up and looked over and didn't have any recollection of what had happened."
32-year-old recovering female binge drinker
High-Dose Use: Hangover
Hangover, a withdrawal syndrome, is the body's response to excessive amounts of alcohol. The effects of a hangover can be most severe many hours after alcohol has been completely eliminated from the system. Typical effects include nausea, vomiting, headache, thirst, dizziness, mood disturbances, abbreviated sleep, sensitivity to light and noise, dry cottony mouth, inability to concentrate, and a general depressed feeling. Some research shows that those with a high susceptibility to alcoholism suffer more severe hangovers and often continue drinking to find relief (NIAAA, 1998). Those with a genetic risk for alcoholism experience more acute withdrawal symptoms and more severe hangovers (Span & Earleywine, 1999).
The causes of hangover are not clearly understood. Additives (congeners) in alcoholic beverages are thought to be partly responsible although even pure alcohol can cause hangovers. Irritation of the stomach lining by alcohol may contribute to intestinal disorders. Low blood sugar, dehydration, and tissue degradation may also play their parts. Symptoms vary according to individuals but it is evident that the greater the quantity of alcohol consumed, the more severe the aftereffects (Swift & Davison, 1998).
High-Dose Use:Sobering Up
A person can control the amount of alcohol in the blood by controlling the amount drunk and the rate at which it is drunk. But the elimination of alcohol from the system is a constant. As mentioned, the body metabolizes alcohol at the rate of 1/4 oz. to 1/3 oz. per hour. Until the alcohol has been eliminated and until hormones, enzymes, body fluids, and bodily systems come into equilibrium, hangover symptoms will persist. An analgesic may lessen the headache pain while fruit juice can help hydrate the body and correct low blood sugar but neither coffee, nor exercise, nor a cold shower cures a hangover. Feeling better comes only with rest and sufficient recovery time.
CHRONIC HIGH-DOSE USE
Chronic High-Dose Use: Tolerance & Tissue Dependence
The effect of alcohol on different drinkers varies widely due to the varying rates at which tolerance develops. Dispositional (metabolic) tolerance, pharmacodynamic tolerance, behavioral tolerance, and acute tolerance are four ways the body tries to adapt to the effects of alcohol and protect itself. The result of tolerance is that the chronic drinker is able to handle larger and larger amounts of alcohol. It also increases the body's dependence on alcohol to stay in physiological balance (tissue dependence).
"Well I started drinking one beer and then I went on to two. A week later I went on to a six-pack, and then through the years I went on to two six-packs and then I ended up drinking tequila. I used to drink a fifth of tequila two years after I got addicted to the alcohol. So I drank tequila most of the day and I used to numb myself."
38-year-old recovering female alcoholic
Dispositional (metabolic) tolerance means the body changes the way it metabolizes alcohol. As a person drinks over a period of time, the liver adapts to create more enzymes to process the alcohol and its metabolite acetylaldehyde (Tabakoff, 1992; Lieber, 1991). This accelerated process eliminates alcohol more quickly from the body. It also accelerates the elimination of other prescription drugs lessening their effectiveness. In addition since liver cells are also being destroyed by drinking and by the natural aging process, the liver eventually becomes less able to handle the alcohol. A heavy drinker who could handle a fifth of whiskey at the age of 30 can become totally incapacitated by half a pint of wine at the age of 50. This process is called "reverse tolerance."
"In the very beginning I got sick, which was a signal. But I thought that happened to everybody. As time went on I learned to develop a tolerance for it and I could drink an awful lot. But then eventually that reversed and it didn't take very much for me to get drunk and out of control and I had blackouts and things like that."
37-year-old recovering alcoholic
Pharmacodynamic tolerance means brain neurons and other cells become more resistant to the effects of alcohol by increasing the number of receptor sites needed to produce an effect or by creating other cellular changes that make tissues less responsive to alcohol. When GABA receptors are activated by ethanol, they change over time to become less sensitive not only to ethanol but to GABA, benzodiazepines, and other GABA agonists as well (Valenzuela & Harris, 1997).
Figure 5-5. This graph shows the decrease in liver capacity to process alcohol as a person ages. As the liver is taxed and poisoned by the alcohol, its capacity is diminished to the point where an older chronic drinker can get tipsy on just one drink.