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For many people, the facts about alcoholism are not clear. What is alcoholism, exactly? How does it differ from alcohol abuse? When should a person seek help for a problem related to his or her drinking? The National Institute on Alcohol Abuse and Alcoholism (NIAAA) has prepared this booklet to help individuals and families answer these and other common questions about alcohol problems. The information below will explain alcoholism and alcohol abuse, symptoms of each, when and where to seek help, treatment choices, and additional helpful resources.

A Widespread Problem

For most people, alcohol is a pleasant accompaniment to social activities. Moderate alcohol use--up to two drinks per day for men and one drink per day for women and older people (A standard drink is one 12-ounce bottle of beer or wine cooler, one 5-ounce glass of wine, or 1.5 ounces of 80-proof distilled spirits) -- is not harmful for most adults. Nonetheless, a substantial number of people have serious trouble with their drinking. Currently, nearly 14 million Americans--1 in every 13 adults--abuse alcohol or are alcoholic. Several million more adults engage in risky drinking patterns that could lead to alcohol problems. In addition, approximately 53 percent of men and women in the United States report that one or more of their close relatives have a drinking problem.

The consequences of alcohol misuse are serious--in many cases, life-threatening. Heavy drinking can increase the risk for certain cancers, especially those of the liver, esophagus, throat, and larynx (voice box). It can also cause liver cirrhosis, immune system problems, brain damage, and harm to the fetus during pregnancy. In addition, drinking increases the risk of death from automobile crashes, recreational accidents, and on-the-job accidents and also increases the likelihood of homicide and suicide. In purely economic terms, alcohol-use problems cost society approximately $100 billion per year. In human terms, the costs are incalculable.

What Is Alcoholism?

Alcoholism, which is also known as "alcohol dependence syndrome," is a disease that is characterized by the following elements:

' Craving: A strong need, or compulsion, to drink.

' Loss of control: The frequent inability to stop drinking once a person has begun.

' Physical dependence: The occurrence of withdrawal symptoms, such as nausea, sweating, shakiness, and anxiety, when alcohol use is stopped after a period of heavy drinking. These symptoms are usually relieved by drinking alcohol or by taking another sedative drug.

' Tolerance: The need for increasing amounts of alcohol in order to get "high.

Alcoholism has little to do with what kind of alcohol one drinks, how long one has been drinking, or even exactly how much alcohol one consumes. But it has a great deal to do with a person's uncontrollable need for alcohol. This description of alcoholism helps us understand why most alcoholics can't just "use a little willpower" to stop drinking. He or she is frequently in the grip of a powerful craving for alcohol, a need that can feel as strong as the need for food or water. While some people are able to recover without help, the majority of alcoholic individuals need outside assistance to recover from their disease. With support and treatment, many individuals are able to stop drinking and rebuild their lives.

Many people wonder: Why can some individuals use alcohol without problems, while others are utterly unable to control their drinking? Recent research supported by NIAAA has demonstrated that for many people, a vulnerability to alcoholism is inherited. Yet it is important to recognize that aspects of a person's environment, such as peer influences and the availability of alcohol, also are significant influences. Both inherited and environmental influences are called "risk factors." But risk is not destiny. Just because alcoholism tends to run in families doesn't mean that a child of an alcoholic parent will automatically develop alcoholism.

What Is Alcohol Abuse?

Alcohol abuse differs from alcoholism in that it does not include an extremely strong craving for alcohol, loss of control, or physical dependence. In addition, alcohol abuse is less likely than alcoholism to include tolerance (the need for increasing amounts of alcohol to get "high"). Alcohol abuse is defined as a pattern of drinking that is accompanied by one or more of the following situations within a 12-month period:

' Failure to fulfill major work, school, or home responsibilities;

' Drinking in situations that are physically dangerous, such as while driving a car or operating machinery;

' Recurring alcohol-related legal problems, such as being arrested for driving under the influence of alcohol or for physically hurting someone while drunk;

' Continued drinking despite having ongoing relationship problems that are caused or worsened by the effects of alcohol.

While alcohol abuse is basically different from alcoholism, it is important to note that many effects of alcohol abuse are also experienced by alcoholics.

What Are the Signs of a Problem?

How can you tell whether you, or someone close to you, may have a drinking problem? Answering the following four questions can help you find out. (To help remember these questions, note that the first letter of a key word in each of the four questions spells "CAGE.")

' Have you ever felt you should Cut down on your drinking?

' Have people Annoyed you by criticizing your drinking?

' Have you ever felt bad or Guilty about your drinking?

' Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (Eye opener)?

One "yes" response suggests a possible alcohol problem. If you responded "yes" to more than one question, it is highly likely that a problem exists. In either case, it is important that you see your doctor or other health care provider right away to discuss your responses to these questions. He or she can help you determine whether you have a drinking problem and, if so, recommend the best course of action for you.

Even if you answered "no" to all of the above questions, if you are encountering drinking-related problems with your job, relationships, health, or with the law, you should still seek professional help. The effects of alcohol abuse can be extremely serious--even fatal--both to you and to others.

The Decision To Get Help

Acknowledging that help is needed for an alcohol problem may not be easy. But keep in mind that the sooner a person gets help, the better are his or her chances for a successful recovery.

Any reluctance you may feel about discussing your drinking with your health care professional may stem from common misconceptions about alcoholism and alcoholic people. In our society, the myth prevails that an alcohol problem is somehow a sign of moral weakness. As a result, you may feel that to seek help is to admit some type of shameful defect in yourself. In fact, however, alcoholism is a disease that is no more a sign of weakness than is asthma or diabetes. Moreover, taking steps to identify a possible drinking problem has an enormous payoff--a chance for a healthier, more rewarding life.

When you visit your health care provider, he or she will ask you a number of questions about your alcohol use to determine whether you are experiencing problems related to your drinking. Try to answer these questions as fully and honestly as you can. You also will be given a physical examination. If your health care professional concludes that you may be dependent on alcohol, he or she may recommend that you see a specalist in diagnosing and treating alcoholism. You should be involved in making referral decisions and have all treatment choices explained to you.

Getting Well

Alcoholism Treatment

The nature of treatment depends on the severity of an individual's alcoholism and the resources that are available in his or her community. Treatment may include detoxification (the process of safely getting alcohol out of one's system); taking doctor-prescribed medications, such as disulfiram (Antabuse') or naltrexone (ReViaTM), to help prevent a return to drinking once drinking has stopped; and individual and/or group counseling. There are promising types of counseling that teach recovering alcoholics to identify situations and feelings that trigger the urge to drink and to find new ways to cope that do not include alcohol use. Any of these treatments may be provided in a hospital or residential treatment setting or on an outpatient basis.

Because the involvement of family members is important to the recovery process, many programs also offer brief marital counseling and family therapy as part of the treatment process. Some programs also link up individuals with vital community resources, such as legal assistance, job training, child care, and parenting classes.

Alcoholics Anonymous

Virtually all alcoholism treatment programs also include meetings of Alcoholics Anonymous (AA), which describes itself as a "worldwide fellowship of men and women who help each other to stay sober." While AA is generally recognized as an effective mutual help program for recovering alcoholics, not everyone responds to AA's style and message, and other recovery approaches are available. Even those who are helped by AA usually find that AA works best in combination with other elements of treatment, including counseling and medical care.

Can Alcoholism Be Cured?

While alcoholism is a treatable disease, a cure is not yet available. That means that even if an alcoholic has been sober for a long while and has regained health, he or she remains susceptible to relapse and must continue to avoid all alcoholic beverages. "Cutting down" on drinking doesn't work; cutting out alcohol is necessary for a successful recovery.

However, even individuals who are determined to stay sober may suffer one or several "slips," or relapses, before achieving long-term sobriety. Relapses are very common and do not mean that a person has failed or cannot eventually recover from alcoholism. Keep in mind, too, that every day that a recovering alcoholic has stayed sober prior to a relapse is extremely valuable time, both to the individual and to his or her family. If a relapse occurs, it is very important to try to stop drinking once again and to get whatever additional support is needed to abstain from drinking.

Help for Alcohol Abuse

If your health care provider determines that you are not alcohol dependent but are nonetheless involved in a pattern of alcohol abuse, he or she can help you:

' Examine the benefits of stopping an unhealthy drinking pattern.

' Set a drinking goal for yourself. Some people choose to abstain from alcohol, while others prefer to limit the amount they drink.

' Examine the situations that trigger your unhealthy drinking patterns, and develop new ways of handling those situations so that you can maintain your drinking goal.

Some individuals who have stopped drinking after experiencing alcohol-related problems choose to attend AA meetings for information and support, even though they have not been diagnosed as alcoholic.

New Directions

With NIAAA's support, scientists at medical centers and universities throughout the country are studying alcoholism. The goal of this research is to develop better ways of treating and preventing alcohol problems. Today, NIAAA funds approximately 90 percent of all alcoholism research in the United States. Some of the more exciting investigations focus on the causes, consequences, treatment, and prevention of alcoholism:

Genetics: Alcoholism is a complex disease. Therefore, there are likely to be many genes involved in increasing a person's risk for alcoholism. Scientists are searching for these genes, and have found areas on chromosomes where they are probably located. Powerful new techniques may permit researchers to identify and measure the specific contribution of each gene to the complex behaviors associated with heavy drinking. This research will provide the basis for new medications to treat alcohol-related problems.

Treatment: NIAAA-supported researchers have made considerable progress in evaluating commonly used therapies and in developing new types of therapies to treat alcohol-related problems. One large-scale study sponsored by NIAAA found that each of three commonly used behavioral treatments for alcohol abuse and alcoholism'motivation enhancement therapy, cognitive-behavioral therapy, and 12-step facilitation therapy'significantly reduced drinking in the year following treatment. This study also found that approximately one-third of the study participants who were followed up either were still abstinent or were drinking without serious problems 3 years after the study ended. Other therapies that have been evaluated and found effective in reducing alcohol problems include brief intervention for alcohol abusers (individuals who are not dependent on alcohol) and behavioral marital therapy for married alcohol-dependent individuals.

Medications development: NIAAA has made developing medications to treat alcoholism a high priority. We believe that a range of new medications will be developed based on the results of genetic and neuroscience research. In fact, neuroscience research has already led to studies of one medication'naltrexone (ReViaTM)'as an anticraving medication. NIAAA-supported researchers found that this drug, in combination with behavioral therapy, was effective in treating alcoholism. Naltrexone, which targets the brain's reward circuits, is the first medication approved to help maintain sobriety after detoxification from alcohol since the approval of disulfiram (Antabuse') in 1949. The use of acamprosate, an anticraving medication that is widely used in Europe, is based on neuroscience research. Researchers believe that acamprosate works on different brain circuits to ease the physical discomfort that occurs when an alcoholic stops drinking. Acamprosate should be approved for use in the United States in the near future, and other medications are being studied as well.

Combined medications/behavioral therapies: NIAAA-supported researchers have found that available medications work best with behavioral therapy. Thus, NIAAA has initiated a large-scale clinical trial to determine which of the currently available medications and which behavioral therapies work best together. Naltrexone and acamprosate will each be tested separately with different behavioral therapies. These medications will also be used together to determine if there is some interaction between the two that makes the combination more effective than the use of either one alone.

In addition to these efforts, NIAAA is sponsoring promising research in other vital areas, such as fetal alcohol syndrome, alcohol's effects on the brain and other organs, aspects of drinkers' environments that may contribute to alcohol abuse and alcoholism, strategies to reduce alcohol-related problems, and new treatment techniques. Together, these investigations will help prevent alcohol problems; identify alcohol abuse and alcoholism at earlier stages; and make available new, more effective treatment approaches for individuals and families.