There is a Japanese proverb that describes the slide into the uncontrolled use of alcohol: ‘First the man takes a drink, then the drink takes a drink, then the drink takes the man’. There are hundreds of thousands of people in any country of the world where alcohol is widely used, who fit this description. They are people who seem to have no control over whether they drink or not. On the other hand, there are many millions of people for whom drinking remains a pleasant and largely harmless social activity – a means of relaxation, an accompaniment to good food and conversation, and a way of overcoming mild anxiety. However, alcohol is a drug and a potent one at that. It has a largely depressant effect which is first ex-perienced by those parts of the brain that are evol-utionarily the most developed. This means that ‘older’ parts of the brain are released from conscious control. The spontaneous, lively, extrovert behaviour characteristic of mild intoxication is the result.
Production of alcohol
Alcohol is produced by fermentation: a natural pro-cess in which the single-celled fungus, yeast, converts sugar to carbon dioxide and alcohol. (Strictly speaking, alcohol is a term that describes several similar chemicals. The substance produced by yeast and which we drink is ethyl alcohol, also called ethanol, the chemical formula of which is C2H5OH). Yeast ferments sugar until the concentration of alcohol reaches 12 to 13 per cent. At this point, the yeast dies of intoxication. That marks the limit of the strength of wine. Drinks such as sherry and port, which are called fortified wines, have extra alcohol added. This alcohol, and that found in spirits, is obtained by distillation, a nonorganic process of refinement in which alcohol is separated from water and concentrated. This can be done because alcohol has a lower boiling point than water and so becomes a vapour more quickly. The vapour is then collected separately and condensed by cooling. Strength, that is alcohol content, is one way in which drinks differ. They are also clearly dissimilar in taste, smell and colour and these differences are due mostly to chemicals called congeners. The characteristics of the drink depend on the source from which the sugar has come. Grapes produce wine; grain and hops, beer; grain and maize, whisky; sugar cane, rum; honey, mead; and grain, vodka.
Absorption of alcohol
Alcohol is absorbed through the wall of the stomach, but most enters the bloodstream from the small intes-tine. The presence of food slows absorption. Since the psychological effect of alcohol depends on the rate of absorption as well as on the total amount drunk, eating in conjunction with drinking can produce quite different effects. With average stomach contents, alcohol levels in the blood, and so in the brain, reach their peak between 30 and 45 minutes after alcohol is drunk.
About 90 per cent of the alcohol we drink is broken down in our livers by an enzyme called alcohol-dehy-drogenase. Some of this enzyme is already naturally present in the body, perhaps because bacteria in everyone’s gastro-intestinal tract produce a small amount of alcohol. In people who drink, however, levels of alcohol-dehydrogenase increase. Most drugs cause the body to increase enzyme production and this is one of the reasons why regular drinkers become tolerant of alcohol’s effects. In the process of breaking down alcohol, certain biochemical changes occur in the body. One is an increase in blood levels of uric acid, which has been associated with the development of gout, a kind of arthritis. Another is an increase in fat in the blood and liver. Fat in the liver is a symptom of disease, and a forerunner of cirrhosis of the liver, but not all heavy drinkers develop the problem. The only way the removal of alcohol from the body can be speeded up is by consuming large quantities of fruit sugar, or fructose. This is not a convenient way of speeding alcohol metabolism, because the quantities of fructose which need to be eaten would make most people sick. Caffeine, which many people take after drinking in the form of strong black coffee, does not increase the rate at which alcohol is broken down, although it is possible that the stimulant effects of caffeine on the brain go some way towards countering the depressant effects of alcohol.
Even though alcohol breakdown cannot be accelerated by drugs, there is recent evidence that intoxication can be countered by substances which block the effects of narcotics such as morphine. This is an inter- esting development since the ability of alcohol to relieve pain (its analgesic effects) and to produce euphoria have never been properly explained. Although alcohol and morphine intoxication are very different things, it is possible that the brain mechanisms inderlying their effects are in some way linked.
Effects of alcohol
As with other drugs, the effects of alcohol on a person’s mood owe much to individual expectation and social situation. The results can be liveliness, aggression or melancholy, depending on the initial frame of mind of the person who drinks, and his or her circumstances.
When it comes to performing tasks, however, certain general rules apply. With very low doses of alcohol performance may be better, especially where previous lack of confidence has been a problem. At moderate to high doses, on the other hand, people usually do worse than when sober. This is so even when people feel they are doing well, as in the case of driving a car. Alcohol is used by most societies and has been around since prehistory. The word for ‘mead’, for example, goes back through Anglo-Saxon to Ancient Greek and Sanskrit. Is is probable that most societies have found that some of their members drank to excess, but at the same time it is likely that no society has had a firm idea of where ‘normal’ drinking becomes ‘ab-normal’. Probably our best definition is that drinking becomes abnormal when it starts to produce medical and social problems.
At some stage, most people have experienced the unpleasant side-effects of having had too much to drink. The characteristic headache, upset stomach and thirst felt the ‘morning after’ are caused by the combined effects of impurities in the alcohol, the dehydration of body cells and a fall in the sugar levels of the blood. The severity of a hangover depends not only on how much alcohol has been consumed, but on what the person has been drinking: ‘homebrews’, for example, are more likely to contain impurities than commercial spirits; and many people suffer from what is colloquially referred to as a ‘red head’ caused by the impurities in red wine. Habitual drinkers are also less likely to suffer a hangover than the person who drinks only occasionally.
Popular remedies to alleviate the worst symptoms of a hangover are as varied as they are generally ineffective. The ‘hair of the dog’ may indeed give a temporary respite from a hangover, but the addition of alco-hol to the bloodstream simply delays the effects. Methods which will go some way to reduce the severity of the symptoms include drinking lots of water before going to bed and taking aspirin and sugary drinks. Bland drinks, such as milk, will also help soothe the stomach.
It should be remembered that alcohol takes about 18 hours to be eliminated from the bloodstream, so even while suffering from a hangover you may still be drunk.
Alcohol contributes to the conviviality of many social situations. If you are going to a party, for example, and want to drink, but not too much, there are some useful strategies to follow: eating a good meal, with lots of protein, will delay the absorption of alcohol in the stomach; carbonated drinks, such as a gin and tonic, should be avoided because the bubbles speed up absorption; alternating alcoholic drinks with a glass of mineral water will also reduce overall consumption.
Problems of alcoholism
An alcoholic is a person who drinks, has problems that are caused by drinking, but who goes on drinking anyway. The kinds of problems caused by excessive drinking can be divided into the social, medical and psychological.
Social problems include loss of employment through repeatedly turning up late for work, or through inca-pacity caused by intoxication and its after-effects; delinquency due to the aggressive behaviour that alcohol may induce, or the need to steal to buy suffi-cient supplies of drink; and the breakdown of mar-riage. There is also the massive involvement of alco-hol in road traffic accidents, which can have a catas-trophic effect on both the victims and the person reponsible, and which represent a major burden on society.
Medical problems can be short- or long-term. Alcohol is a poison, and it is just about possible to literally drink yourself to death if the brain centres controlling respiration are sufficiently depressed – although the vomiting reflex usually prevents this from happening. When drinking is implicated as a cause of death it is usually because alcohol has been combined with some other powerful drug. But the ‘hangover’ felt the morning after a night’s heavy drinking is a gentle reminder that the body can be severely affected even by short-term alcohol abuse. The long-term medical problems that are most frequently and most clearly associated with alcohol are those that affect the liver, which has the job of detoxifying the body of the drug. Excessive alcohol consumption can lead to cirrhosis of the liver; there is also the possibility that a high consumption of alcohol increases the risk of cancer of the liver. There are other long-term effects too. The stomach may become inflamed (gastritis) and the nerves start to degenerate. There may be loss of brain tissue of up to ten per cent, which shows up on X-rays as an increase in the size of the fluid-filled ventricles, although research on this point is not yet conclusive. In men, excessive drinking is suspected of causing impotence and feminization: the breasts enlarge and body v hair is lost. This is because alcohol decreases the body’s production of male sex hormones, although the precise reason is unknown. Having said that, small amounts of alcohol (two or three drinks per day) may have a slight protective effect on the heart and circulatory system, making them more resilient to disease. It is possible, for example, that alcohol reduces the tendency of blood platelets to clot, which would be beneficial. As with most attempts to relate disease (or its absence) to patterns of drug use, the evidence is not conclusive.
Another possible alcohol-related problem is the ‘fetal alcohol syndrome’.The evidence suggests that drinking during pregnancy may damage the unborn child. It seems that babies born to mothers who drink heavily (three drinks per day say some researchers) are likely to have characteristic facial features, be overactive and possibly suffer from various forms of mental retardation and deformity.
There is evidence to support the idea from research on animals: if pregnant rats are given large amounts of alcohol, cells in the developing brain of the fetus do not migrate to the correct places. It is not at all certain that the same phenomenon occurs in humans. However, some researchers suggest that, to be safe, pregnant women should not drink at all. Others regard small amounts of alcohol late in pregnancy – when most critical stages of development are passed – as acceptable.
One of the reasons the medical effects of alcohol are difficult to pin-point is that heavy drinking is usually associated with poor nutrition. One gram of alcohol contains seven Calories. This is a potential cause of obesity if normal food intake is maintained. It also means that drinking can replace eating as far as energy needs are concerned: alcoholics can literally ‘run on spirit’. If they do, although energy requirements are met, nutritional needs are not. Alcoholics can then become seriously deficient in important vitamins and this will in itself increase the likelihood of disease. Medical opinion differs as to the amount of alcohol that can be safely drunk. In most discussions on alco-hol, including this one, ‘drink’ is roughly one single measure of spirits or its equivalent in wine or beer. Four glasses of wine (twothirds of a bottle) per day, or their equivalent, might be considered the maximum advisable for a man, and three glasses of wine for a woman.
Why are women more at risk than men? Two reasons are straightforward: one is that most women weigh less, by about 20 per cent, so there is simply less tissue through which the alcohol can diffuse; the other is that a greater proportion of a woman’s tissues is fat, which does not absorb alcohol, thus increasing the concentration of alcohol in tissues that do. A third reason is more speculative. It seems that alcoholic liver disease is in some respects an auto-immune disorder, in which the body’s defence mechanisms turn against itself. Women are more prone to auto-im-mune disease, although scientists do not know why.
Turning from the medical effects of alcohol to the psychological, the most important difference between normal and abnormal drinking seems to lie in the reason for alcohol use. People usually drink to feel better; the alcoholic drinks to avoid feeling worse. This is because the body becomes so dependent on alcohol that it can no longer function properly without it. The result is a compulsion to keep on drinking to avoid the unpleasant effects of drug withdrawal. The person develops a preoccupation with alcohol. Before going anywhere he or she must be assured that supplies will be available. At the same time there is self-deception. The person denies to himself or herself that alcohol has come to play the ruling part in their life. Yet there is also guilt, felt at times of sobriety, that alcohol has this degree of importance. The result of these conflicting feelings is anxiety and depression, which, in a vicious circle, may lead to renewed alcohol consumption. Heavy drinking can also lead to trem-bling and the hallucinations – particularly of insects crawling all over the body – typical of the syndrome known as delirium tremens.
The beginnings of a drink problem sometimes go unnoticed. You may be at risk if any of the following applies: . you automatically reach for a drink if you have had a bad day, or are under pressure, . you are impatient for the first drink of the day, . you sometimes have memory blackouts after a bout of drinking.
A more serious drink problem may have developed if: . other people often discuss your drinking, . you want to carry on drinking after others have stopped, . you prefer to drink with strangers.
Help should definitely be sought if: . you need a drink to be able to face the day, . you often feel depressed about your drinking, . you are sometimes drunk for several days at a stretch, . you sometimes see or hear imaginary things, . you find that you cannot drink as much as you were once able to.
Causes of alcoholism
Explanations of alcoholism are as varied as its symp-toms, covering biological, psychological and social perspectives. Each gives an insight into the problem but no single account is adequate without also refer-ring to the others.
Biological accounts suggest that the alcoholic is pre-disposed to develop the problem because of some abnormality in the body’s ability to metabolize alco-hol, or because he or she is particularly sensitive to the drug. There is good evidence for an inherited, genetic susceptibility to alcoholism. The children of parents who are alcoholic run a high risk of becoming alcoholics themselves, even if they are brought up away from their parents by people who do not have an alcohol problem. Rates of alcoholism are also much higher among the relatives of alcoholics than in the general population. This demonstrates that biological factors may be playing a part.
Psychological theories portray the alcoholic as having a personality which is particularly vulnerable to ex-cessive use of alcohol. The psychoanalytic approach, pioneered by Sigmund Freud (1856-1939), suggests that the alcoholic has an immature personality and uses drink as a way of coping with unresolved con-flicts, particularly those relating to the parents. Other ideas are that alcoholics are especially anxious people who become dependent on the tranquillising effects of the drug; or that they use alcohol to compensate for frustrated ambitions and feelings of inferiority. If alcohol does play a major part in meeting a person’s psychological needs, the repeated association between drinking and the relief of unpleasant feelings will lead to the development of a powerful habit. One of the techniques used to help alcoholics involves breaking this learned association by making them feel nauseous every time they take a drink and by training them in other ways to cope with their unpleasant feelings, using techniques such as relaxation. Neither the biological nor the psychological approach adequately accounts for the social and cultural factors which inluence alcohol use. Working with alcohol, as a licensee, for example, is a clear risk factor, but so is being a doctor, journalist or businessman. This is because certain professional groups have permissive attitudes towards alcohol. Those who work alone and largely unsupervised with nobody checking on them, are also at risk. The reverse is true of religions such as Judaism, Mormonism and Islam. Here attitudes to alcohol are strict, use is limited, and the risk of developing a drink problem is slight. Environmental stress is also important: marital disharmony, unemployment and bereavement are all associated with heavy drinking.