Signs of Alcoholism: How to Tell Alcohol Abuse Has Turned Into Addiction

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Alcohol, or ethanol, is one of the most commonly used psychoactive substances in the world. In part because of its widespread use and acceptance, alcohol abuse and addiction are also very common. Nearly one-third of the U.S. population will experience alcohol addiction at some point in their life with fewer than 25% of those with it seeking.¹⁴ There are many signs of alcoholism to look for if you’re concerned that someone you love (or even yourself) is addicted to alcohol.

Knowing the Signs of Alcoholism

Perhaps the most noticeable way alcohol affects someone is on their behavior, which varies from person to person. Excessive drinking (blood alcohol ranges of .06 – 0.2) can cause some people to be loud and talkative, while others may become withdrawn. Some people become angry and aggressive, at times leading to abusive behavior and violence. Still, others may experience dramatic mood swings, with signs of boisterousness or aggression as well as withdrawal or severe depression.⁷

Genetics and Environmental Factors

How someone reacts to alcohol depends largely on their genetic makeup as well as their current and past environment. Genetic makeup can determine how someone metabolizes alcohol and how alcohol interacts with a person’s brain chemistry, leading at times to person-specific and sometimes unexpected behaviors.

There is data that alcoholism can be passed down through a person’s genes.¹⁹ Past and current environments can also strongly influence your response to alcohol. Some individuals, for example, are exposed to environments that accept and even encourage heavy drinking, while others have little or no exposure to alcohol use or abuse.

For this reason, it’s important to look for signs of alcoholism in those who have had family members who have been alcoholics.

Amount of Alcohol Consumed

Another important factor when considering alcohol’s effects is how much is consumed. Recommendations for alcohol use usually stipulate no more than two “standard drinks” per day for men and 1 standard drink per day for women.¹⁶ However, research shows that even this much is detrimental to your health.

Women are advised to drink less for several reasons, including the fact that they generally weigh less and do not metabolize alcohol the same way as men. Women also have proportionally less body water compared to men, even when you consider the differences in size and weight. These factors mean that alcohol is more concentrated in women’s blood than in men’s.¹⁷

When Does Alcohol Use Become Abuse?

A “standard drink” is considered:

• 12 oz of beer, 5% alcohol by volume
• 8-9 fl oz of malt liquor
• 5 oz of wine, 12% alcohol by volume
• 1.5 oz of spirits, 40% alcohol by volume

These numbers are important to keep in mind because the term “drink” can be misleading. For example, when someone orders a “double” or pours significantly more than 1.5 oz of distilled spirits into a single glass, they might actually be consuming more than “one drink.”⁹

Some alcoholic beverages may also contain much more alcohol than the “standard” amount. Alcohol can be as high as 8-12% by volume in some beers, for example. Many cocktails, including mojitos, margaritas, or martinis, contain more than 1 standard drink in a single glass. Port, a sweet dessert wine, contains approximately 18% – 20% alcohol by volume. These are examples of when calculating alcohol consumption isn’t always straightforward. Factoring in these differences, however, is important when making distinctions between healthy and unhealthy drinking habits.

Unhealthy Drinking Habits: One of the First Signs of Alcoholism

“Unhealthy” levels of alcohol consumption can be difficult to evaluate, especially when considering society’s widespread use and acceptance of alcohol. Under the umbrella of unhealthy levels of alcohol consumption are several different terms, which are categorized by severity.

On the lower end of severity is alcohol misuse. Alcohol misuse is a pattern of heavier drinking (or “binge drinking”)—defined as five or more drinks in one occasion for men, four or more for women—that can lead to social, legal, or health problems.¹⁵ Alcohol abuse is a continued pattern of alcohol misuse despite the social, legal, or health problems it causes.⁷

Alcoholism, also known as alcohol dependence or addiction, is defined as the body’s physical need or dependence on alcohol. There is also “Alcohol Use Disorder (AUD),” which is a term used by mental health professionals to diagnose individuals with alcohol problems. AUD can capture symptoms of either or both alcohol abuse and dependence, and is diagnosed by severity (mild, moderate, or severe). Severe AUD and alcoholism are considered interchangeable.¹⁹ For purposes of clarity, the terms alcoholism or alcohol addiction will be used for the remainder of this article.

Common Signs of Alcoholism

Alcohol misuse may result in intoxication and some social or health problems. This, however, is not the same as alcohol addiction or alcoholism. Alcoholism involves moderate to severe impairments in psychological, social, and physical health functioning that alcohol misuse doesn’t. Some psychological signs of alcoholism include:

• Cravings for alcohol
• Drinking more than intended
• Continued drinking despite the mental and physical health complications it is causing, such as liver or heart disease, malnutrition, depression, and alcoholic ketoacidosis
• Engaging in unsafe behaviors while intoxicated (e.g., driving or operating machinery under the influence, having unprotected sex, etc.)

Functional signs of alcoholism include:

• Impairment to occupational functioning (e.g., job loss, working drunk or hungover)
• Relationship impairments (e.g., friendships, parental roles, romantic relationships)
• Spending excess money and/or time obtaining or consuming alcohol

Physical signs of alcoholism include withdrawal symptoms, such as:

• Tremors or “shakes”
• Anxiety
• Insomnia
• Rapid heart rate
• Fatigue
• Headache
• Nausea or vomiting

It is important to note that while alcohol withdrawals occur largely without medical complication, they can be very dangerous. In a subsect of individuals, alcohol withdrawals can reach an extreme state of severity called Delirium Tremens. Symptoms of Delirium Tremens include:

• Agitation
• Fever
• Seizures
• Confusion
• Hallucinations (seeing or hearing things that aren’t there)

Delirium Tremens is a state of emergency and should be addressed immediately.¹⁸ Generally, withdrawal symptoms and the prevention of Delirium Tremens are best addressed with supervised detoxification. Even if someone is not at risk for Delirium Tremens, supervised detoxification can help prevent relapse, which is common during withdrawal.

First Signs of Alcoholism To Look For

It is important to note that while alcohol misuse and addiction are not the same thing, alcohol misuse is a risk factor for developing addiction.² Predicting whether a person will become addicted to alcohol is nearly impossible, but there are some early warning signs and risk factors.

Perhaps most importantly are the social, psychological, and physical effects of alcohol. Ask  yourself several questions about the person you’re concerned about:

• Are they isolating, withdrawing, or cutting off ties with people close to them?
• Are their relationships hurting or deteriorating?
• Are they gaining or losing weight?
• Do they look more disheveled or more poorly groomed?
• Are they struggling at work or struggling to take care of themselves?
• Are there any reasons to believe that alcohol might be impacting their physical health (e.g., blood pressure, heart health, liver functioning)?
• Do they appear down or blue, anxious, or more aggressive than usual?

Yes to any of these questions may indicate a problem.

Other risk factors are genetics and mental illness. Alcoholism is heritable, meaning that it can be passed down through genes. Some experts estimate 50% of the risk of developing alcoholism is attributable to genetics.¹⁷

Mental illnesses like depression, anxiety, bipolar disorder, and schizophrenia also increase the risk for developing alcohol addiction.¹² On the other hand, addiction can also create or make mental health symptoms worse.¹³  Alcoholism is also one of the highest risk factors for suicide.¹

Treatment for Alcoholism

Approximately 70% of individuals with alcohol addiction or risky drinking behavior experience “natural recovery,” meaning recovery without treatment.¹⁴ This statistic is misleading, however, because the majority are lower-risk drinkers vs those with a severe alcohol problem.¹⁴ Additionally, individuals who do experience “natural recovery” may do so only after inflicting significant damage to their health.

Confronting someone about their alcohol abuse or addiction can be difficult for several reasons. People who feel ashamed about their addiction or abuse may hide their drinking. They may also downplay the problems it’s causing.

Even when signs of problem drinking or alcoholism are more apparent, there are several reasons individuals deny needing treatment.  Thus, it is important to remember that decisions about treatment for alcoholism, or any addiction for that matter, should involve the person in need of treatment.

If someone is unsure about treatment, motivational interviewing may be a good first step. Motivational interviewing is a non-judgmental therapeutic approach that encourages you to examine problematic alcohol use and evaluate the need for treatment. It can, also in some cases, reduce drinking frequency.¹⁰

Once someone has decided to seek treatment, selecting the appropriate course will depend on the individual; both their preference for treatment and the severity of their drinking. Problematic alcohol use that hasn’t turned into an addiction, especially if withdrawal symptoms are not present, can be treated with behavioral therapy only.

Individuals who regularly consume high quantities of alcohol often require medically supervised detox because they are more likely to experience potentially fatal withdrawal symptoms.

Detox

Supervised detox is medically monitored to ensure comfort, prevent relapse, and address physical or psychological complications that can arise during withdrawal. Medications received during the detoxification process will depend on your health status, withdrawal symptoms, and the functioning of your organ systems, like the kidneys and liver.

A common class of medication used during detox is benzodiazepines (e.g., Librium). Benzodiazepines like Librium help decrease the severity of withdrawal symptoms by balancing uneven levels of neurotransmitters caused by prolonged, heavy drinking. Benzodiazepines also calm the body’s neurological system, which becomes agitated during withdrawal from alcohol.⁶

Medically supervised detox is part of a general approach to treatment called medically-assisted treatment, or MAT. MAT is supported by the scientific community as a way of successfully treating alcohol and other drug addiction and can involve supervised detoxification, treatment planning, and counseling.

Once supervised detox is c completed, or near completion, other medications may be introduced to reduce cravings for alcohol and prevent relapse. The two most effective and commonly prescribed medications are Acamprosate and Naltrexone. Naltrexone has the added benefit of reducing the euphoric feelings that accompany alcohol when consumed. It does this by blocking opioid receptors in the brain, which contribute to alcohol’s pleasure-causing effects.¹¹

Medications and Therapy

Other medications that are sometimes used are Disulfiram, Gabapentin, and Topiramate. Disulfiram is an Antabuse medication that has been approved to treat alcoholism since 1949.⁴ Disulfiram blocks the enzyme responsible for metabolizing a toxic component of alcohol. The result is a cluster of undesirable effects (e.g., nausea, vomiting, flushing) when you drink alcohol. Topiramate and Gabapentin are both anti-seizure medications that are prescribed off-label for alcoholism. Both medications are believed to reduce cravings.¹¹

Medications are not a stand-alone treatment. Behavioral therapy is also encouraged during alcoholism treatment. Results show that a combination of therapy and medication has the lowest rates of relapse.10 Therapy for alcohol addiction varies, but the most studied and effective is cognitive behavioral therapy, or CBT.¹⁰ CBT examines and works to modify thoughts, emotions, and behaviors associated with alcohol use.

References

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10. Ray, L. A., Meredith, L. R., Kiluk, B. D., Walthers, J., Carroll, K. M., & Magill, M. (2020). Combined pharmacotherapy and cognitive behavioral therapy for adults with alcohol or substance use disorders. JAMA network open, 3(6), e208279-e208279.

11. Reus, V. I., Fochtmann, L. J., Bukstein, O., Eyler, A. E., Hilty, D. M., Horvitz-Lennon, M., … & McIntyre, J. (2018). The American Psychiatric Association practice guideline for the pharmacological treatment of patients with alcohol use disorder. American Journal of Psychiatry, 175(1), 86-90.

12. Riper, H., Andersson, G., Hunter, S. B., de Wit, J., Berking, M., & Cuijpers, P. (2014). Treatment of comorbid alcohol use disorders and depression with cognitive‐behavioural therapy and motivational interviewing: A meta‐analysis. Addiction, 109(3), 394-406.

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14. Tucker, J. A., Chandler, S. D., & Witkiewitz, K. (2020). Epidemiology of Recovery From Alcohol Use Disorder. Alcohol research: current reviews, 40(3), 02.

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16. U.S. National Library of Medicine. (2020, November 09). Alcohol. Retrieved December 05, 2020.

17. Foroud, T. (2010). Genetic Research: Who is at Risk for Alcoholism? Alcohol Research & Health. 33(1-2):64-75.

18. U.S. National Library of Medicine. (2019, January 10). Alcohol withdrawal: MedlinePlus Medical Encyclopedia. Retrieved December 7, 2020.

19. Verhulst, B., Neale, M. C., & Kendler, K. S. (2015). The heritability of alcohol use disorders: a meta-analysis of twin and adoption studies. Psychological medicine, 45(5), 1061–1072.