Alcohol is the most popular recreational drug in America, with nearly 90% of adults¹ having consumed alcohol at some point, and nearly 60% of adults and 20% of teenagers reporting that they consume alcohol at least monthly. In spite of its popularity, alcohol is a potent toxin that is associated with substantial risks to the health and wellbeing of people who consume it excessively.

35%² of people with alcohol use disorders will develop advanced liver disease, and alcoholic liver disease is the number one reason³ why people need to get a liver transplant. The liver is not the only organ that is damaged by excessive alcohol consumption: Cardiovascular disease⁴, hypertension, stroke, autonomic dysfunction⁵, some types of cancer⁶, and pancreatic disease⁷ are all linked to excessive alcohol use. In addition, recent studies have shown that chronic alcohol intake is linked to cognitive decline⁸ in older adults.

Can alcoholism kill? Alcohol is the third most common cause⁹ of preventable death in the US. 88,000 people die every year from alcohol-related causes, and 31% of driving fatalities involve alcohol. The Centers for Disease Control and Prevention (CDC) reported that six people die every day¹⁰ from alcohol poisoning.

What is Alcoholism, or Alcohol Use Disorder?

According to the 2018 National Survey on Drug Use and Health (NSDUH), approximately 15 million adults⁹ meet the criteria for alcohol use disorder (AUD, also known as alcoholism), but less than 10% receive any form of professional treatment. The Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) defines AUD¹¹ as a “problematic pattern of drinking leading to clinically significant impairment and distress for at least 12 months,” and has outlined 11 criteria for AUD¹⁹.

Stages of Alcoholism

There are three main stages of alcoholism: Early, middle, and end (or late). Some addiction experts include a fourth “pre-alcoholic” stage to describe the alcohol abuse that precedes the development of AUD.

Stage 1: Early Stage Alcoholism

Early-stage alcoholism is characterized by increasing alcohol use and the development of tolerance, but without necessarily drinking so much that it becomes obviously problematic. However, it is important to understand that excessive consumption leads to alcohol dependence, meaning that the brain is dependent on alcohol in order to function without experiencing debilitating withdrawal symptoms. People in early-stage alcoholism have developed some degree of tolerance and dependence, but they can function normally without alcohol.

Signs of early-stage AUD include:

• Drinking more frequently than normal
• Drinking to manage stress, boredom or loneliness
• Preferring social activities that include alcohol
• Creating reasons to use alcohol

Stage 2: Middle-Stage Alcoholism

People in middle-stage alcoholism require alcohol in order to function normally. Chronic excessive alcohol use is associated with the development of a physical dependence on alcohol. Middle stage alcoholics need alcohol to feel normal and, if they don’t drink, they will experience uncomfortable withdrawal symptoms like trembling, nausea, sweating, and irritability.

Signs of middle stage AUD include:

• Drinking habitually in non-social settings
• Loss of interest in alcohol-free social activities
• Strained relationships with friends and loved ones
• Withdrawal symptoms set in when alcohol isn’t being consumed

Stage 3: End-Stage Alcoholism

People who reach end-stage alcoholism are physically dependent on alcohol. Drinking is not an option but a requirement. End-stage alcoholics have a high risk for serious, even life-threatening diseases like alcoholic liver disease and cardiovascular disease.

People with end-stage alcoholism cannot safely quit drinking on their own. Chronic heavy alcohol use causes substantial changes in brain chemistry¹³, most notably by increasing levels of the inhibitory neurotransmitter GABA and reducing the effectiveness of the excitatory neurotransmitter NMDA. The combined effect of these changes reduces overall brain activity. If someone in end-stage alcoholism abruptly quits drinking, GABA and NMDA levels quickly return to normal, effectively removing the “brake” on activity in brain cells. The result is cellular hyperexcitability, which can cause seizures, delirium tremens or heart attack.

Signs of late-stage AUD include:

• Malnutrition
• Cognitive decline
• Erratic behavior
• Financial and/or legal troubles
• Serious health problems

Signs & Symptoms

There are some common signs of alcoholism that can help people determine whether they or someone they love is at risk for developing an AUD, including:

• Loss of interest in hobbies or activities
• Avoiding social events that don’t serve alcohol
• Drinking alone
• Drinking during the day
• Hiding alcohol use
• Drinking and driving

Symptoms of alcoholism are experienced by the person who has developed alcohol dependence, and often includes:

• Being unable to cut down or stop drinking
• Preoccupation with alcohol
• Drinking despite negative health and/or social consequences
• Requiring large amounts of alcohol to achieve the desired effect
• Drinking to prevent withdrawal

Withdrawal & Detox Process

Anyone who wants to quit drinking should make an appointment with an addiction specialist who can help them make a plan. Alcohol withdrawal symptoms can be dangerous and may require medical intervention, so alcohol detoxification should be done under professional supervision.

Alcohol Withdrawal Symptoms

Even people with early-stage AUD may experience the following withdrawal symptoms when they aren’t drinking:

• Headache
• Irritability
• Anxiety
• Cravings
• Insomnia (See: How to Sleep without Alcohol)
• Restlessness

Withdrawal symptoms that are associated with middle and end-stage AUD include:

• Pronounced tremors
• Profuse sweating
• Low-grade fever
• Nausea/vomiting
• Diarrhea
• Rapid breathing and heart rate
• Psychomotor agitation (repetitive, purposeless motions)
• Increased anxiety and emotional stress

Severe alcohol withdrawal may include additional symptoms that can be life-threatening without medical intervention. Dangerous symptoms of alcohol withdrawal include:

• Respiratory depression
• Seizures
• Delirium tremens (hallucinations, delirium, confusion, loss of touch with reality)
• Heart attack

Alcohol Withdrawal Timeline

Early, middle and end-stage alcohol withdrawal have slightly different timelines, and the duration can vary to some degree between individuals. Symptom onset generally occurs 6-8 hours after the last drink. Mild and moderate withdrawal symptom severity peaks around 72 hours after the last drink and often resolve within about one week. Severe AUD withdrawal can take several weeks to fully resolve.

Post-acute withdrawal syndrome (PAWS) is a frustrating phenomenon that affects a minority of people who successfully completed detox and acute withdrawal. PAWS is characterized by persistent withdrawal symptoms that fluctuate in intensity and may last for weeks, months, or, in extreme cases, years after quitting drinking.

Alcohol Addiction Treatment Levels of Care

Overcoming alcohol use disorders can be challenging, but there are several treatment options. Importantly, anyone who wants to quit drinking should seek a consultation with an addiction specialist.

Comprehensive alcoholism treatment often involves medical detox, residential rehab, outpatient rehab, and aftercare:

• Medical detox: In some cases, alcohol withdrawal can be very dangerous. Medical detox provides 24/7 supervision by medical professionals who can intervene in the case of complications, and medications that can reduce withdrawal symptom severity may be prescribed
• Residential rehab: Following medical detox, most people transition into a residential (inpatient) rehab program. Residential rehab provides a safe environment and evidence-based treatments like cognitive behavioral therapy to help people overcome addiction and learn how to manage stress, triggers, and temptation
• Outpatient rehab: People in early-stage AUD might start their recovery process in an intensive outpatient program, while others will move into outpatient treatment after successfully completing a residential program. Outpatient rehab options range from intensive programs that require a substantial time commitment to weekly therapy sessions
• Aftercare: For many people, aftercare programs are an important component in long-term recovery from AUD. Aftercare programs vary quite a bit, but the goal is the same: Provide people in recovery with resources and support as they reorient to a sober lifestyle

Relapse rates are high among people with alcohol use disorder, but there is evidence that professional inpatient treatment programs reduce relapse rates, especially for people with end-stage alcoholism.

Pharmacological Approaches to AUD Treatment

Alcohol use disorder, like other types of addiction, is a disease that is caused by significant structural and chemical changes in the brain. Pharmacological treatments may help restore normal brain function and minimize the risk of alcohol relapse.

There are currently three FDA-approved medications for AUD treatment:

• Disulfiram: Disulfiram affects how alcohol is metabolized. When someone taking disulfiram drinks alcohol, they experience very unpleasant side effects, including vomiting, headache, and increased heart rate. The goal of this drug is to prevent people in recovery from using alcohol
• Acamprosate: Although the exact mechanism is unclear, acamprosate is thought to normalize some of the brain signaling pathways that are dysregulated in AUD. Acamprosate reduces cravings and the desire to use alcohol
• Naltrexone: Like acamprosate, naltrexone reduces alcohol cravings. Naltrexone inhibits activity in the endogenous opioid system, which is a key driver of addiction

FAQs

Answers to some frequently asked questions about alcohol addiction are provided.

How addictive is alcohol?

There is no simple answer to this question. For some people, alcohol is a powerfully addictive drug, while other people can drink chronically without developing an addiction. The risk for addiction increases as tolerance develops because more alcohol is required to achieve the desired effect. Tolerance often develops in parallel with dependence, which occurs when the brain becomes dependent on alcohol to function “normally.”

What causes alcoholism?

There is one major cause of alcoholism: excessive alcohol consumption. Other causes of alcoholism include biological and environmental factors. Drinking in moderation (maximum of one drink per day for women and two drinks per day for men), or not drinking at all, is the best way to prevent alcoholism.

What are the risk factors for alcoholism?

There are several alcoholism risk factors, but how much influence they have varies from person to person. The most important risk factor is regular heavy drinking. The contribution of genetics to alcohol use disorder (AUD) development is an area of active research. Many studies have found that AUD heritability is between 10-20%, but some estimates are as high as 50%.

Risk factors include:

Regular heavy drinking

Genetics

Family history

Mental health/psychiatric disorders

Alcohol use during adolescence

Stress

Trauma

Boredom

Easy access

Social influences