substance-related disorders

11 substance-related disorders

image1

learning objectives 11

·  11.1 What is alcohol abuse and dependence?

·  11.2 What is drug abuse and dependence?

·  11.3 Are there addictive disorders other than alcohol and drugs?

Remarkable Recoveries from Life-Threatening Substance Abuse Lyle Prouse was born in Wichita, Kansas, in 1938 of American Indian heritage. As a child he was very interested in aviation and won his first airplane ride by writing an essay for Beechcraft Aircraft Company. Prouse, who grew up in the Indian community in Wichita, had a serious, long-term substance abuse problem, as did his parents, both of whom died from alcohol abuse. Many of his friends and associates were heavy alcohol abusers. After he finished high school he joined the U.S. Marines, became a pilot, and served in the Vietnam War. He was awarded several medals for his service in Vietnam. He left the military and obtained a flying position at Northwest Airlines, where he attained the rank of captain and worked for 22 years, flying Boeing 727 passenger aircraft.

In 1990, Captain Prouse and his flight crew enjoyed a night of heavy drinking while on a layover in Fargo, North Dakota. Prouse consumed a number of rum-and-Diet-Cokes, and his crew drank several pitchers of beer and apparently were very loud and belligerent. Although his crew left the bar earlier, Prouse remained longer and continued drinking. During their drinking binge the flight crew angered a customer in the pub, who later called the FAA, warning them against the problem drinking of the crew. The next morning the Northwest crew continued their flight to Minneapolis and were arrested and given substance use tests. They showed high levels of alcohol in their bloodstreams and were charged with violating a federal law, which included prison time as a result of operating a public transportation carrier under the influence of drugs or alcohol. Captain Prouse and his crewmembers served 12 months of the 16-month sentence they received. All three pilots lost their jobs and their pilot’s licenses as a result of the substance use violations.

Captain Prouse felt a great deal of depression and shame at the problems that he created for himself and others following the loss of the aviation career that he loved. He also experienced a great deal of financial problems from his employment termination. On several occasions he contemplated committing suicide. Captain Prouse entered inpatient substance abuse treatment not long after the incident.

After completing his recovery in an inpatient substance abuse treatment center, Prouse began a long and difficult process of rehabilitation and effort to restore his life without using alcohol. He made many public speeches describing his substance abuse and later wrote a book detailing what he had gone through (Prouse,  2001 ). Throughout his recovery he was determined to regain his flying status. It was necessary for him to retrain and retake all of the FAA licensing examinations in order to have his qualifications restored because he was required to requalify for every one of his licenses and ratings.

Captain Prouse was assisted in his recovery by a number of people who were impressed by his public disclosure of wrong-doing and his high motivation to recover from his substance abuse. After he appealed to the court to allow him the opportunity to obtain recertification, the court waived the legal restrictions that had been placed upon him at the trial. A friend of his who owned a trainer aircraft allowed him to earn the necessary flying time needed to be relicensed as a pilot. The CEO of Northwest Airlines, John Dasburg, who himself had grown up in a family with alcoholic abuse problems, took personal interest in Prouse’s struggle and encouraged his return to duty. He returned to flying with Northwest Airlines. Captain Prouse’s efforts and success at rehabilitation were indeed impressive. In 2001 he was granted a presidential pardon by President Clinton.

Interestingly, another one of the pilots on the Northwest “drunk pilots” flight, flight engineer Joe Balzer, who also spent 12 months in federal prison, also rehabilitated himself. He became involved with Alcoholics Anonymous and, over time, requalified for the aviation certification, eventually returning to the cockpit as a pilot for American Airlines (see his autobiographical account in Balzer,  2009 ).

The extensive problem of substance abuse and substance dependence in our society has drawn both public and scientific attention. Although our present knowledge is far from complete, investigating these problems as maladaptive patterns of adjustment to life’s demands, with no social stigma involved, has led to clear progress in understanding and treatment. Such an approach, of course, does not mean that an individual bears no personal responsibility in the development of a problem. On the contrary, individual lifestyles and personality features are thought by many to play important roles in the development of substance-related disorders and are central themes in some types of treatment.

Substance-related disorders  can be seen all around us: in extremely high rates of alcohol abuse and dependence, and in tragic exposés of cocaine abuse among star athletes and entertainers.  Addictive behavior —behavior based on the pathological need for a substance—may involve the abuse of substances such as nicotine, alcohol, Ecstasy, or cocaine. Addictive behavior is one of the most prevalent and difficult-to-treat mental health problems facing our society today.

The most commonly used problem substances are those that affect mental functioning in the central nervous system (CNS)— psychoactive substances : alcohol, nicotine, barbiturates, tranquilizers, amphetamines, heroin, Ecstasy, and marijuana. Some of these substances, such as alcohol and nicotine, can be purchased legally by adults; others, such as barbiturates or pain medications like OxyContin (or marijuana in some states), can be used legally under medical supervision; still others, such as heroin, Ecstasy, and methamphetamine, are illegal.

The material described in this chapter was designed to provide both a historic and contemporary view of important research and theoretical strategies in understanding addictive disorders thus we will, in places, refer to the substance abuse versus substance dependence distinction. The following distinctions are important to understanding and diagnosing substance-related disorders:

·  •  Substance abuse  generally involves an excessive use of a substance resulting in (1) potentially hazardous behavior such as driving while intoxicated or (2) continued use despite a persistent social, psychological, occupational, or health problem.

·  •  Substance dependence  includes more severe forms of substance-use disorders and usually involves a marked physiological need for increasing amounts of a substance to achieve the desired effects. Dependence in these disorders means that an individual will show a tolerance for a drug and/or experience withdrawal symptoms when the drug is unavailable.

·  •  Tolerance —the need for increased amounts of a substance to achieve the desired effects—results from biochemical changes in the body that affect the rate of metabolism and elimination of the substance from the body.

·  •  Withdrawal  refers to physical symptoms such as sweating, tremors, and tension that accompany abstinence from the drug.

image2

The picture shows an 1891 Stale Beer Dive on Mulberry Street Bend, New York, with several drunk people from the neighborhood and includes beers being served by a young girl (Campbell et al.,  1892 ).

Alcohol Related Disorders

The terms  alcoholic  and  alcoholism  have been subject to some controversy and have been used differently by various groups in the past. The World Health Organization no longer recommends the term alcoholism but prefers the term alcohol dependence syndrome—“a state, psychic and usually also physical, resulting from taking alcohol, characterized by behavioral and other responses that always include a compulsion to take alcohol on a continuous or periodic basis in order to experience its psychic effects, and sometimes to avoid the discomfort of its absence; tolerance may or may not be present” (1992, p. 4). However, because the terms alcoholic and alcoholism are still widely used in practice, in scientific journals, and in government agencies and publications, we will sometimes use them in this book.

People of many ancient cultures, including the Egyptians, Greeks, Romans, and Israelites, made extensive and often excessive use of alcohol. Beer was first made in Egypt around 3000 B.C. The oldest surviving wine-making formulas were recorded by Marcus Cato in Italy almost a century and a half before the birth of Christ. About A.D. 800, the process of distillation was developed by an Arabian alchemist, thus making possible an increase in both the range and the potency of alcoholic beverages. Problems with excessive use of alcohol were observed almost as early as its use began. Cambyses, King of Persia in the sixth century B.C., has the dubious distinction of being one of the early alcohol abusers on record.

The Prevalence, Comorbidity, and Demo Graphics of Alcohol Abuse and Dependence

Alcohol abuse and alcohol dependence are major problems in the United States and are among the most destructive of the psychiatric disorders because of the impact excessive alcohol use can have upon users’ lives and those of their families and friends. It is estimated that 50 percent of adults who are 18 or older are current regular drinkers and only 21 percent are lifetime abstainers (Pleis et al.,  2009 ). In 2008, 23.3 percent of Americans aged 12 or older reported binge drinking, and 6.7 percent were found to be heavy drinkers (Substance Abuse and Mental Health Services Administration,  2010 ). An estimated 12.4 percent of persons 12 or older drove under the influence of alcohol at least once over the past year. An estimated 22.2 million persons (8.9 percent of the population aged 12 or older) were classified with substance dependence or abuse in the past year based on DSM diagnostic criteria. In this sample, 3.1 million people were classified with dependence on or abuse of both alcohol and illicit drugs, 3.9 million were dependent on or abused illicit drugs but not alcohol, and 15.2 million were dependent on or abused alcohol but not illicit drugs (Substance Abuse and Mental Health Services Administration,  2009 ).

DSM-5 criteria for: Alcohol Use Disorder

·  A. A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:

·  1. Alcohol is often taken in larger amounts or over a longer period than was intended.

·  2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.

·  3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.

·  4. Craving, or a strong desire or urge to use alcohol.

·  5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home.

·  6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.

·  7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use.

·  8. Recurrent alcohol use in situations in which it is physically hazardous.

·  9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.

·  10. Tolerance, as defined by either of the following:

·  a. A need for markedly increased amounts of alcohol to achieve intoxication or desired effect.

·  b. A markedly diminished effect with continued use of the same amount of alcohol.

·  11. Withdrawal, as manifested by either of the following:

·  a. The characteristic withdrawal syndrome for alcohol (refer to Criteria A and B of the criteria set for alcohol withdrawal, pp. 499–500).

·  b. Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.

Source: Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright © 2013). American Psychiatric Association.

The potentially detrimental effects of excessive alcohol use—for an individual, his or her loved ones, and society—are legion. Heavy drinking is associated with vulnerability to injury (Cherpitel  1997 ), marital discord (Hornish & Leonard,  2007 ), and becoming involved in intimate partner violence (Eckhardt,  2007 ). The life span of the average person with alcohol dependence is about 12 years shorter than that of the average person without this disorder. Alcohol significantly lowers performance on cognitive tasks such as problem solving—and the more complex the task, the more the impairment (Pickworth et al.,  1997 ). Organic impairment, including brain shrinkage, occurs in a high proportion of people with alcohol dependence (Gazdzinski et al.,  2005 ), especially among binge drinkers—people who abuse alcohol following periods of sobriety (Hunt,  1993 ).

One study reported that of the 1.3 million emergency room visits associated with drug misuse or abuse in 2007, 7 percent involved alcohol abuse in patients under age 21 (USDHHS, 2010). Cherpitel and colleagues ( 2006 ) explored the association of alcohol use and emergency room (ER) services among injured patients in several countries. Of 9,743 injured patients surveyed in 37 ERs in 14 countries, drinking within 6 hours before injury was associated with prior visits to the ER during the last 12 months. People who were heavy drinkers or were alcohol dependent were significantly more likely to report multiple prior emergency room visits.

Alcohol abuse is associated with over 40 percent of the deaths suffered in automobile accidents each year (Chou et al.,  2006 ) and with about 40 to 50 percent of all murders (Bennett & Lehman,  1996 ), 40 percent of all assaults, and over 50 percent of all rapes (Abbey et al.,  2001 ). About one of every three arrests in the United States is related to alcohol abuse, and over 43 percent of violent encounters with the police involve alcohol (McClelland & Teplin,  2001 ). In research on substance abuse and violent crime, Dawkins ( 1997 ) found that alcohol is more frequently associated with both violent and nonviolent crime than drugs such as marijuana and that people with violence- related injuries are more likely to have a positive Breathalyzer test (Cherpitel,  1997 ). Of the 1 million violent crimes that were suspected to be alcohol related in 2002, 30 percent of them were determined to involve alcohol use on the part of the offender. Two-thirds of cases in which victims suffered violence from an intimate (a current or former spouse) were alcohol related (U.S. Department of Justice,  2006 ).

image3

Alcohol is associated with over 40 percent of deaths and serious injuries suffered in automobile accidents in the United States each year (see Chou et al.,  2006 ).

Alcohol abuse and alcohol dependence in the United States cut across all age, educational, occupational, and socioeconomic boundaries. Alcohol abuse is found in priests, politicians, surgeons, law enforcement officers, and teenagers; the image of the alcohol-abusing person as an unkempt resident of skid row is clearly inaccurate. Alcohol abuse is considered a serious problem in industry, in the professions, and in the military as well. Recent research has shown that alcohol abuse has a strong presence in the workplace, with 15 percent of employees showing problem behaviors; many (1.68 percent, or 2.1 million people) actually drinking on the job; and 1.83 percent, or 2.3 million workers, drinking before they go to work (Frone,  2006 ). Some myths about alcoholism are noted in  Table 11.1  on p. 372.

In the past, most problem drinkers—people experiencing life problems as a result of alcohol abuse—were men; for example, men become problem drinkers at about five times the frequency of women (Helzer et al.,  1990 ). Recent epidemiological research has suggested that the traditional gap between men and women has narrowed when it comes to the development of substance abuse disorders (Greenfield et al.,  2010 ). There do not seem to be important differences in rates of alcohol abuse between black and white Americans, although Native Americans tend to have higher rates of alcohol abuse, and Asian Americans tend to have lower usage. It appears that problem drinking may develop during any life period from early childhood through old age. About 10 percent of men over age 65 are found to be heavy drinkers (Breslow et al.,  2003 ). Surveys of alcoholism rates across different cultural groups around the world have found varying rates of the disorder across diverse cultural samples (Caetano et al.,  1998 ; Hibell et al.,  2000 ).

Over 37 percent of alcohol abusers suffer from at least one coexisting mental disorder (Lapham et al.,  2001 ). Not surprisingly, given that alcohol is a depressant, depression ranks high among the mental disorders often comorbid with alcoholism. There is a high comorbidity of substance abuse disorders and eating disorders (Harrop & Marlatt, 2009). It is also no surprise that many alcoholics commit suicide (McCloud et al.,  2004 ). In addition to the serious problems that excessive drinkers create for themselves, they also pose serious difficulties for others (Gortner et al.,  1997 ). Alcohol abuse also co-occurs with high frequency with personality disorder. Grant and colleagues ( 2004 ) report that among individuals with a current alcohol-use disorder, 28.6 percent have at least one personality disorder.

The diagnosis of substance use disorder in DSM-5 is based upon a pathological pattern of behaviors that are related to the use of a particular substance, for example, alcohol. The DSM Criteria for Alcohol Use Disorder are reproduced on page 370 as an illustration. Two additional diagnostic criteria for Alcohol Related Disorders can be found in the DSM-5 manual: Alcohol Intoxication (p. 497) and Alcohol Withdrawal (p. 499).

The Clinical Picture of Alcohol Related Disorders

A great deal of progress has been made in understanding the physiological effects of alcohol on the brain. The first is a tendency toward decreased sexual inhibition but, simultaneously, lowered sexual performance. An appreciable number of alcohol abusers also experience blackouts—lapses of memory. At first these occur at high blood alcohol levels, and a drinker may carry on a rational conversation or engage in other relatively complex activities but have no trace of recall the next day. For heavy drinkers, even moderate drinking can elicit memory lapses. Another phenomenon associated with alcoholic intoxication (intoxication is defined as a state of being affected by one or more psychoactive drugs) is the hangover, which many drinkers experience at one time or another. As yet, no one has come up with a satisfactory explanation of or remedy for the symptoms of headache, nausea, and fatigue that are characteristic of the hangover.

ALCOHOL’S EFFECTS ON THE BRAIN

Alcohol has complex and seemingly contradictory effects on the brain. At lower levels, alcohol stimulates certain brain cells and activates the brain’s “pleasure areas,” which release opium-like endogenous opioids that are stored in the body (Braun,  1996 ). At higher levels, alcohol depresses brain functioning, inhibiting one of the brain’s excitatory neurotransmitters, glutamate, which in turn slows down activity in parts of the brain (Koob et al.,  2002 ). Inhibition of glutamate in the brain impairs the organism’s ability to learn and affects the higher brain centers, impairing judgment and other rational processes and lowering self-control. As behavioral restraints decline, a drinker may indulge in the satisfaction of impulses ordinarily held in check. Some degree of motor uncoordination soon becomes apparent, and the drinker’s discrimination and perception of cold, pain, and other discomforts are dulled. Typically the drinker experiences a sense of warmth, expansiveness, and well-being. In such a mood, unpleasant realities are screened out and the drinker’s feelings of self-esteem and adequacy rise. Casual acquaintances become the best and most understanding of friends, and the drinker enters a generally pleasant world of unreality in which worries are temporarily left behind.

TABLE 11.1 Some Common Misconceptions About Alcohol and Alcohol Abuse

Fiction Fact
Alcohol is a stimulant. Alcohol is actually both a nervous system stimulant and a depressant.
You can always detect alcohol on the breath of a person who has been drinking. It is not always possible to detect the presence of alcohol. Some individuals successfully cover up their alcohol use for years.
One ounce of 86-proof liquor contains more alcohol than two 12-ounce cans of beer. Two 12-ounce cans of beer contain more than an ounce of alcohol.
Alcohol can help a person sleep more soundly. Alcohol may interfere with sound sleep.
Impaired judgment does not occur before there are obvious signs of intoxication. Impaired judgment can occur long before motor signs of intoxication are apparent.
An individual will get more intoxicated by mixing liquors than by taking comparable amounts of one kind—e.g., bourbon, Scotch, or vodka. It is the actual amount of alcohol in the bloodstream rather than the mix that determines intoxication.
Drinking several cups of coffee can counteract the effects of alcohol and enable a drinker to “sober up.” Drinking coffee does not affect the level of intoxication.
Exercise or a cold shower helps speed up the metabolism of alcohol. Exercise and cold showers are futile attempts to increase alcohol metabolism.
People with “strong wills” need not be concerned about becoming substance abusers. Alcohol is seductive and can lower the resistance of even the “strongest will.”
Alcohol cannot produce a true addiction in the same sense that heroin can. Alcohol has strong addictive properties.
One cannot become a substance abuser by drinking just beer. One can consume a considerable amount of alcohol by drinking beer. It is, of course, the amount of alcohol that determines whether one becomes a substance abuser.
Alcohol is far less dangerous than marijuana. There are considerably more individuals in treatment programs for alcohol problems than for marijuana abuse.
In a heavy drinker, damage to the liver shows up long before brain damage appears. Heavy alcohol use can be manifested in organic brain damage before liver damage is detected.
The physiological withdrawal reaction from heroin is considered more dangerous than is withdrawal from alcohol. The physiological symptoms accompanying withdrawal from heroin are no more frightening or traumatic to an individual than alcohol withdrawal. Actually, alcohol withdrawal is potentially more lethal than opiate withdrawal.
Everybody drinks. Actually, 28 percent of men and 50 percent of women in the United States are abstainers.

In most U.S. states, when the alcohol content of the bloodstream reaches 0.08 percent, the individual is considered intoxicated, at least with respect to driving a vehicle. Muscular coordination, speech, and vision are impaired and thought processes are confused. Even before this level of intoxication is reached, however, judgment becomes impaired to such an extent that the person misjudges his or her condition. For example, drinkers tend to express confidence in their ability to drive safely long after such actions are in fact quite unsafe. When the blood alcohol level reaches approximately 0.5 percent (the level differs somewhat among individuals), the entire neural balance is upset and the individual passes out. Unconsciousness apparently acts as a safety device because concentrations above 0.55 percent are usually lethal.

In general, it is the amount of alcohol actually concentrated in the bodily fluids, not the amount consumed, that determines intoxication. The effects of alcohol vary for different drinkers, depending on their physical condition, the amount of food in their stomach, and the duration of their drinking. In addition, alcohol users may gradually build up a tolerance for the drug so that ever-increasing amounts may be needed to produce the desired effects. Women metabolize alcohol less effectively than men and thus become intoxicated on lesser amounts (Gordis et al.,  1995 ).

DEVELOPMENT OF ALCOHOL DEPENDENCE

Excessive drinking can be viewed as progressing insidiously from early- to middle-to late-stage alcohol-related disorder, although some abusers do not follow this pattern. Many investigators have maintained that alcohol is a dangerous systemic poison even in small amounts, but others believe that in moderate amounts it is not harmful to most people. For pregnant women, however, even moderate amounts are believed to be dangerous; in fact, no safe level has been established, as is discussed in Developments in Research box below. The photos on page 374 show the differences between the brain of a normal teenager and those born with fetal alcohol syndrome (FAS), a condition that is caused by excessive alcohol consumption during pregnancy and results in birth defects such as mental retardation.

THE PHYSICAL EFFECTS OF CHRONIC ALCOHOL USE

For individuals who drink to excess, the clinical picture is highly unfavorable (Turner et al.,  2006 ). Alcohol that is taken in must be assimilated by the body, except for about the 5 to 10 percent that is eliminated through breath, urine, and perspiration. The work of alcohol metabolism is done by the liver, but when large amounts of alcohol are ingested, the liver may be seriously overworked and eventually suffer irreversible damage (Lucey et al.,  2009 ). In fact, from 15 to 30 percent of heavy drinkers develop cirrhosis of the liver, a disorder that involves extensive stiffening of the blood vessels. About 40 to 90 percent of the 26,000 annual cirrhosis deaths every year are alcohol related (Parrish et al.,  1991 ). Some countries, for example Britain and Scotland, have shown an increase in cirrhosis-related deaths in the last two decades because of the increased use of alcohol in their populations (Leon & McCambridge,  2006 ).

developments in RESEARCH: Fetal Alcohol Syndrome: How Much Drinking Is Too Much?

Research indicates that heavy drinking by expectant mothers can affect the health of unborn babies, particularly binge drinking and heavy drinking during the early days of pregnancy (Burd & Christensen,  2009 ; Calhoun & Warren,  2007 )—a condition known as fetal alcohol syndrome. Newborn infants whose mothers drank heavily during pregnancy have been found to have frequent physical and behavioral abnormalities (Alison,  1994 ), including aggressiveness and destructiveness (Gardner,  2000 ), and may experience symptoms of withdrawal (Thomas & Riley,  1998 ). For example, such infants have shown growth deficiencies, facial and limb irregularities, damage to the central nervous system, and impairment in cognitive functioning (Kodituwakku et al.,  2001 ). Neuroimaging research has shown that there is an overall reduction of brain size and prominent brain shape abnormalities, with narrowing in the parietal region along with reduced brain growth in portions of the frontal lobe (Spadoni et al.,  2007 ). Moreover, children with FAS often show significant working memory deficits and altered activations patterns in some brain regions (Astley et al.,  2009 ).

As noted in The Third Report on Alcohol and Health (HEW,  1978 ), alcohol abuse in pregnant women is the third-leading cause of birth defects—the first two being Down syndrome and spina bifida (the incomplete formation and fusion of the spinal canal). Although data on FAS are often difficult to obtain, the prevalence has been estimated at between 0.5 and 2 cases per 1,000 births (May & Gossage,  2001 ).

How much drinking endangers a newborn’s health? The HEW report warns against drinking more than 1 ounce of alcohol per day (one 12-ounce can of beer or one 5-ounce glass of wine, for example). The actual amount of alcohol that can safely be ingested during pregnancy is not known, but existing evidence for FAS is strongest when applied to binge drinkers or heavy alcohol users rather than to light or moderate users (Kolata,  1981 ). Nonetheless the surgeon general and many medical experts have concurred that pregnant women should abstain from using alcohol as the “safest course” until the safest amount of alcohol consumption can be determined (Raskin,  1993 ).

image4

The effects of FAS can be both dramatic and long-lasting. This young child who had been diagnosed with FAS shows some of the permanent physical abnormalities characteristic of the syndrome.

image5

MRIs of three teenagers: (left) normal control, 13-year-old female; (center) FAS, 13-year-old male with focal thinning of the corpus callosum; (right) FAS, 14-year-old male with complete agenesis (nondevelopment) of the corpus callosum.

Alcohol is also a high-calorie drug. A pint of whiskey—enough to make about eight to ten ordinary cocktails—provides about 1,200 calories, which is approximately half the ordinary caloric requirement for a day (Flier et al.,  1995 ). Thus consumption of alcohol reduces a drinker’s appetite for other food. Because alcohol has no nutritional value, the excessive drinker can suffer from malnutrition (Derr & Gutmann,  1994 ). Furthermore, heavy drinking impairs the body’s ability to utilize nutrients, so the nutritional deficiency cannot be made up by popping vitamins. Many alcohol abusers also experience increased gastrointestinal symptoms such as stomach pains (Fields et al.,  1994 ).

PSYCHOSOCIAL EFFECTS OF ALCOHOL ABUSE AND DEPENDENCE

In addition to various physical problems, a heavy drinker usually suffers from chronic fatigue, oversensitivity, and depression. Initially, alcohol may seem to provide a useful crutch for dealing with the stresses of life, especially during periods of acute stress, by helping screen out intolerable realities and enhance the drinker’s feelings of adequacy and worth. The excessive use of alcohol eventually becomes counterproductive, however, and can result in impaired reasoning, poor judgment, and gradual personality deterioration. Behavior typically becomes coarse and inappropriate, and the drinker assumes increasingly less responsibility, loses pride in personal appearance, neglects spouse and family, and becomes generally touchy, irritable, and unwilling to discuss the problem. image6 Watch the Video Chris: Alcoholism on MyPsychLab

image7

As judgment becomes impaired, an excessive drinker may be unable to hold a job and generally becomes unqualified to cope with new demands that arise (Frone,  2003 ). General personality disorganization and deterioration may be reflected in loss of employment and marital breakup. By this time, the drinker’s general health is likely to have deteriorated, and brain and liver damage may have occurred. For example, there is some evidence that an alcoholic’s brain is accumulating diffuse organic damage even when no extreme organic symptoms are present (Sullivan, Deshmukh, et al.,  2000 ), and even mild to moderate drinking can adversely affect memory and problem solving (Gordis,  2001 ). Other researchers have found extensive alcohol consumption to be associated with an increased amount of organic damage in later life (Lyvers,  2000 ); however, recent research using fMRI has shown that this damage is partially reversible if the person abstains from alcohol use (Wobrock et al.,  2009 ).

PSYCHOSES ASSOCIATED WITH SEVERE ALCOHOL ABUSE

Excessive use of alcohol can result in severe mental health problems. Several acute psychotic reactions fit the diagnostic classification of substance-induced disorders. These reactions may develop in people who have been drinking excessively over long periods of time or who have a reduced tolerance for alcohol for other reasons—for example, because of brain lesions from excessive long-term use. Such acute reactions usually last only a short time and generally consist of confusion, excitement, and delirium. There is some evidence that delirium may be associated with lower levels of thiamine in alcoholics (Holzbeck,  1996 ). These disorders are often called “alcoholic psychoses” because they are marked by a temporary loss of contact with reality.

Among those who drink excessively for a long time, a reaction called  alcohol withdrawal delirium (formerly known as  delirium tremens ) may occur (Palmstierno,  2001 ). This reaction usually happens following a prolonged drinking spree when the person enters a state of withdrawal. Slight noises or suddenly moving objects may cause considerable excitement and agitation. The full-blown symptoms include (1) disorientation for time and place, in which, for example, a person may mistake the hospital for a church or jail, no longer recognize friends, or identify hospital attendants as old acquaintances; (2) vivid hallucinations, particularly of small, fast-moving animals like snakes, rats, and roaches; (3) acute fear, in which these animals may change in form, size, or color in terrifying ways; (4) extreme suggestibility, in which a person can be made to see almost any animal if its presence is merely suggested; (5) marked tremors of the hands, tongue, and lips; and (6) other symptoms including perspiration, fever, a rapid and weak heartbeat, a coated tongue, and foul breath.

The delirium typically lasts from 3 to 6 days and is generally followed by a deep sleep. When a person awakens, few symptoms—except for possibly slight remorse—remain, but frequently the individual is badly scared and may not resume drinking for several weeks or months. Usually, however, drinking is eventually resumed, followed by a return to the hospital with a new attack. The death rate from withdrawal delirium as a result of convulsions, heart failure, and other complications once approximated 10 percent (Tavel,  1962 ). With drugs such as chlordiazepoxide, however, the current death rate during withdrawal delirium and acute alcoholic withdrawal has been markedly reduced.

A second alcohol-related psychosis is persisting alcohol disorder or alcohol amnestic disorder (formerly known as Korsakoff’s syndrome). This condition was first described by the Russian psychiatrist Korsakoff in 1887 and is one of the most severe alcohol-related disorders (d’Ydewalle & Van Damme,  2007 ). The outstanding symptom is a memory defect (particularly with regard to recent events), which is sometimes accompanied by falsification of events (confabulation). Persons with this disorder may not recognize pictures, faces, rooms, and other objects that they have just seen, although they may feel that these people or objects are familiar. Such people increasingly tend to fill in their memory gaps with reminiscences and fanciful tales that lead to unconnected and distorted associations. These individuals may appear to be delirious, delusional, and disoriented for time and place, but ordinarily their confusion and disordered actions are closely related to their attempts to fill in memory gaps. The memory disturbance itself seems related to an inability to form new associations in a manner that renders them readily retrievable. Such a reaction usually occurs in long-time alcohol abusers after many years of excessive drinking. These patients have also been observed to show other cognitive impairments such as planning deficits (Brokate et al.,  2003 ), intellectual decline, emotional deficits (Snitz et al.,  2002 ), judgment deficits (Brand et al.,  2003 ), and cortical lesions (Estruch et al.,  1998 ).

The symptoms of alcohol amnestic disorder are now thought to be due to vitamin B (thiamine) deficiency and other dietary inadequacies. Although it had been believed that a diet rich in vitamins and minerals generally restores such a patient to more normal physical and mental health, some research evidence suggests otherwise. Lishman ( 1990 ) reports that alcohol amnestic disorder did not respond well to thiamine replacement. Some memory functioning appears to be restored with prolonged abstinence. However, some personality deterioration usually remains in the form of memory impairment, blunted intellectual capacity, and lowered moral and ethical standards.

Alcohol Amnestic Disorder Averill B. was brought into the detoxification unit of a local county hospital by the police after an incident at a crowded city park. He was arrested because of his assaultive behavior toward others (he was walking through the crowded groups of sunbathers muttering to himself, kicking at people). At admission to the hospital, Averill was disoriented (did not know where he was), incoherent, and confused. When asked his name, he paused a moment, scratched his head, and said, “George Washington.” When asked about what he was doing at the park, he indicated that he was “marching in a parade in his honor.”

Biological Causal Factors in the Abuse of and Dependence On Alcohol

In trying to identify the causes of problem drinking, some researchers have stressed the role of genetic and biochemical factors (see Hartz, & Bierut,  2010 ); others have pointed to psychosocial factors, viewing problem drinking as a maladaptive pattern of adjustment to the stress of life; and still others have emphasized sociocultural factors such as the availability of alcohol and social approval of excessive drinking. As we will see, some combination of all of these factors seems to influence risk for developing alcohol abuse or alcohol dependency. As with most other forms of maladaptive behavior, there may be several types of alcohol abuse and dependency, each with somewhat different patterns of biological, psychosocial, and sociocultural causal factors.

How do substances such as alcohol, cocaine, and opium (discussed later in the chapter) come to have such powerful effects—an overpowering hold that occurs in some people after only a few uses of the drug? Although the exact mechanisms are not fully agreed on by experts in the field, two important factors are apparently involved. The first is the ability of most, if not all, addictive substances to activate areas of the brain that produce intrinsic pleasure and sometimes immediate, powerful reward. The second factor involves the person’s biological makeup, or constitution, including his or her genetic inheritance and the environmental influences (learning factors) that enter into the need to seek mind-altering substances to an increasing degree as use continues. The development of an alcohol addiction is a complex process involving many elements—constitutional vulnerability and environmental encouragement, as well as the unique biochemical properties of certain psychoactive substances. Let’s examine each of these elements in more detail.

THE NEUROBIOLOGY OF ADDICTION

Let’s first examine the role that substances like alcohol play in the process of addiction. Psychoactive drugs differ in their biochemical properties as well as in how rapidly they enter the brain. There are several routes of administration—oral, nasal, and intravenous. Alcohol is usually drunk, the slowest route, whereas cocaine is often self-administered by injection or taken nasally. Central to the neurochemical process underlying addiction is the role the drug plays in activating the “pleasure pathway.” The  mesocorticolimbic dopamine pathway (MCLP)  is the center of psychoactive drug activation in the brain. The MCLP is made up of neuronal cells in the middle portion of the brain known as the ventral tegmental area (see  Figure 11.1 ) and connects to other brain centers such as the nucleus accumbens and then to the prefrontal cortex. This neuronal system is involved in such functions as control of emotions, memory, and gratification. Alcohol produces euphoria by stimulating this area in the brain. Research has shown that direct electrical stimulation of the MCLP produces great pleasure and has strong reinforcing properties (Littrell,  2001 ). Other psychoactive drugs also operate to change the brain’s normal functioning and to activate the pleasure pathway. Drug ingestion or behaviors that lead to activation of the brain reward system are reinforced, so further use is promoted. The exposure of the brain to an addictive drug alters its neurochemical structure and results in a number of behavioral effects. With continued use of the drug, neuroadaptation to or tolerance and dependence on the substance develop.

image8

FIGURE 11.1 The Mesocorticolimbic Pathway. The mesocorticolimbic pathway (MCLP), running from the ventral tegmental area to the nucleus accumbens to the prefrontal cortex, is central to the release of the neurotransmitter dopamine and in mediating the rewarding properties of drugs.

Source: Office of Technology Assessment,  1993 image9 Watch the Video In the Real World: Neurotransmitters on MyPsychLab

GENETIC VULNERABILITY

The possibility of a genetic predisposition to developing alcohol-abuse problems has been widely researched. Many experts today agree that heredity probably plays an important role in a person’s developing sensitivity to the addictive power of drugs like alcohol (Plomin & DeFries,  2003 ; Volk et al.,  2007 ). Several lines of research point to the importance of genetic factors in substance-related disorders.

A review of 39 studies of the families of 6,251 alcoholics and of 4,083 nonalcoholics who had been followed over 40 years reported that almost one-third of alcoholics had at least one parent with an alcohol problem (Cotton,  1979 ). Likewise, a study of children of alcoholics by Cloninger and colleagues ( 1986 ) reported strong evidence for the inheritance of alcoholism. They found that for males, having one alcoholic parent increased the rate of alcoholism from 12.4 percent to 29.5 percent and having two alcoholic parents increased the rate to 41.2 percent. For females with no alcoholic parents, the rate was 5.0 percent; for those with one alcoholic parent, the rate was 9.5 percent; and for those with two alcoholic parents, it was 25.0 percent.

Alcohol abuse problems clearly tend to run in families (Hartz & Beirut,  2010 ; Hasin & Katz,  2010 ). Research has shown that some people, such as the sons of alcoholics, have a high risk for developing problems with alcohol because of an inherent motivation to drink or sensitivity to the drug (Conrod et al.,  1998 ). Research on the children of alcoholics who were adopted by other (nonalcoholic) families has also provided useful information. Studies have been conducted of alcoholics’ children who were placed for adoption early in life and so did not come under the environmental influences of their biological parents. For example, Goodwin and colleagues ( 1973 ) found that children of alcoholic parents who had been adopted by nonalcoholic foster parents were nearly twice as likely to have alcohol problems by their late 20s as a control group of adopted children whose biological parents were not alcoholics. In another study, Goodwin and colleagues ( 1974 ) compared alcoholic parents’ sons who were adopted in infancy by nonalcoholic parents and sons raised by their alcoholic parents. Both adopted and nonadopted sons later evidenced high rates of alcoholism—25 percent and 17 percent, respectively. These investigators concluded that being born to an alcoholic parent, rather than being raised by one, increases the risk of a son’s becoming an alcoholic.

Another approach to understanding the precursors to alcohol-related disorders is to study prealcoholic personalities—individuals who are at high risk for substance abuse but who are not yet affected by alcohol. The heritability of personality characteristics has been widely explored (Bouchard & Loehlin,  2001 ). An alcohol-risk personality has been described as an individual (usually an alcoholic’s child) who has an inherited predisposition toward alcohol abuse and who is impulsive, prefers taking high risks, and is emotionally unstable.

Research has shown that prealcoholic men (those who are genetically predisposed to developing drug or alcohol problems but who have not yet acquired the problem) show different physiological patterns than nonalcoholic men in several respects. Prealcoholic men tend to experience a greater lessening of feelings of stress with alcohol ingestion than do nonalcoholic men (Finn et al.,  1997 ). Prealcoholic men also show different alpha wave patterns on EEGs (Stewart et al.,  1990 ) and have been found to have larger conditioned physiological responses to alcohol cues than individuals who were considered at a low risk for alcoholism, according to Earleywine and Finn ( 1990 ). These results suggest that prealcoholic men may be more prone to developing tolerance for alcohol than low-risk men.

Some research suggests that certain ethnic groups, particularly Asians and Native Americans, have abnormal physiological reactions to alcohol—a phenomenon referred to as “alcohol flush reaction.” Fenna and colleagues ( 1971 ) and Wolff ( 1972 ) found that Asian and Eskimo subjects showed a hypersensitive reaction including flushing of the skin, a drop in blood pressure, heart palpitations, and nausea following the ingestion of alcohol (see also Gill et al.,  1999 ). This physiological reaction is found in roughly half of all Asians (Chen & Yeh,  1997 ) and results from a mutant enzyme that fails to break down alcohol molecules in the liver during the metabolic process (Takeshita et al.,  1993 ). Although cultural factors may also play a role, the relatively lower rates of alcoholism among Asian groups might be related to the extreme discomfort associated with the alcohol flush reaction (Higuci et al.,  1994 ).

GENETICS—THE WHOLE STORY?

As with the other disorders described in this book, genetics alone is not the whole story, and the exact role it plays in the development of alcohol-related disorders remains unclear. This issue continues to be debated, and some experts are not convinced of the primary role of genetics in substance-abuse disorders. The genetic mechanism or model for the generally agreed-upon observation that alcoholism is familial is insufficient to explain the behavior fully. That is, genetic transmission in the case of alcohol-related disorders does not follow the hereditary pattern found in strictly genetic disorders. Some investigators have employed the evidence that genetics appears to play a stronger role in men than in women (Merikangas & Swendsen,  1997 ) to question the relative power of genetics as an explanatory factor in substance abuse. Searles ( 1991 ) points to the ambiguous evidence for the genetics of alcohol-related disorders and cautions against interpreting genetics as a causal factor in its development. Negative results have been found in both twin and adoptive studies and in studies designed to follow up the behavior of high-risk individuals. The great majority of children who have parents with alcohol-related problems do not themselves develop substance-abuse disorders—whether or not they are raised by their biological parents. The children of substance abusers who make successful life adjustments have not been sufficiently studied. In one study of high-risk children of substance abusers, a group of young men 19 to 20 years of age who were presumably at high risk for developing substance-abuse problems were carefully studied for symptoms of psycho-pathology. Schulsinger and colleagues ( 1986 ) found that they did not differ in psychopathology or in alcohol-abuse behavior from a control sample similar to the general population. In another study of high-risk individuals, Alterman, Searles, and Hall ( 1989 ) failed to find differences in drinking behavior or alcohol-related symptoms between a group of high-risk subjects (those who had alcoholic fathers) and a group of non-high-risk subjects.

Although much evidence implicates genetic factors in the etiology of alcoholism, we do not know what precise role they play. At present, it appears that the genetic interpretation of alcoholism remains an attractive hypothesis; however, additional research is needed for us to hold this view with confidence. It is not likely that genetics alone will account for the full range of alcohol and drug problems. Social circumstances are still considered powerful forces in providing both the availability and the motivation to use alcohol and other drugs. McGue ( 1998 ) notes that the mechanisms of genetic influence should be viewed as compatible, rather than competitive, with psychological and social determinants of this disorder.

GENETIC INFLUENCES AND LEARNING

When we talk about familial or constitutional differences, we are not strictly limiting our explanation to genetic inheritance. Rather, learning factors appear to play an important part in the development of constitutional or predetermined tendencies to behave in particular ways. Having a genetic predisposition or biological vulnerability to substance abuse, of course, is not a sufficient cause of the disorder. The person must be exposed to the substance to a sufficient degree for the addictive behavior to appear. In the case of alcohol, almost everyone in America is exposed to the drug to some extent—in most cases through peer pressure, parental example, and advertising (Andrews & Hops,  2010 ). The development of alcohol-related problems involves living in an environment that promotes initial as well as continuing use of the substance. People become conditioned to stimuli and tend to respond in particular ways as a result of learning. Learning appears to play an important part in the development of substance abuse and antisocial personality disorders. There clearly are numerous reinforcements for using alcohol in our social environments and everyday lives. However, research has also shown that psychoactive drugs such as alcohol contain intrinsic rewarding properties—apart from the social context or the drug’s operation to diminish worry or frustration. As we saw earlier, the drug stimulates pleasure centers in the brain and develops a reward system of its own.

Psychosocial Causal Factors in Alcohol Abuse and Dependence

Not only do alcohol abusers become physiologically dependent on alcohol, they develop a powerful psychological dependence as well—they become socially dependent on the drug to help them enjoy social situations.

FAILURES IN PARENTAL GUIDANCE

Stable family relationships and parental guidance are extremely important molding influences for children (Hasin & Katz,  2010 ), and this stability is often lacking in families of substance abusers. Children who have parents who are extensive alcohol or drug abusers are vulnerable to developing substance-abuse and related problems (Erblich et al.,  2001 ). The experiences and lessons we learn from important figures in our early years have a significant impact on us as adults. Children who are exposed to negative role models and family dysfunction early in their lives or experience other negative circumstances because the adults around them provide limited guidance often falter on the difficult steps they must take in life (Fischer et al.,  2005 ). These formative experiences can have a direct influence on whether a young person becomes involved in maladaptive behavior such as alcohol or drug abuse.

In one sophisticated program of research aimed at evaluating the possibility that negative socialization factors influence alcohol use, Chassin and colleagues ( 1993 ; Trim & Chassin,  2004 ) replicated findings that alcohol abuse in parents is associated with substance use in adolescents. They then evaluated several possible mediating factors that can affect whether adolescents start using alcohol. They found that parenting skills or parental behavior was associated with substance use in adolescents. Specifically, alcohol-abusing parents are less likely to keep track of what their children are doing, and this lack of monitoring often leads to the adolescents’ affiliation with drug-using peers. In addition, Chassin and colleagues ( 1993 ) found that stress and negative affect (more prevalent in families with an alcoholic parent) are associated with alcohol use in adolescents. They reported that “parental alcoholism was associated with increases in negative uncontrollable life events which, in turn, were linked to negative affect, to associations with drug-using peers, and to substance use” (p. 16). In a follow-up study, Chassin and colleagues ( 1996 ) reported that the direct effect of fathers’ alcohol abuse is strong, even after controlling for stress and negative affect. Extremely stressful childhood experiences such as physical abuse (Douglas et al.,  2010 ; Kaufman et al.,  2007 ) or child sexual abuse might also make a person vulnerable to later problems. Women who have a history of child sexual abuse are at risk for developing a wide range of psychological problems including substance abuse (Kendler et al.,  2000 ).

image10

Parent substance use is associated with early adolescent substance use, and negative parental models can have longer-range negative consequences once children leave home.

PSYCHOLOGICAL VULNERABILITY

Is there an “alcoholic personality”—a type of character organization that predisposes a person to use alcohol rather than adopt some other defensive pattern of coping with stress? Research has suggested that personality factors related to having a family history of alcoholism are associated with the development of alcohol-use disorders (Larkins & Sher,  2006 ). Research has shown that children of alcoholics progressed more quickly from initial alcohol use to the onset of disorder than did matched adolescents in the control sample (Hussong et al.,  2008 ).

Do some individuals self-medicate or reduce their discomfort by excessive use of alcohol? In efforts to answer this question, investigators have found that many potential alcohol abusers tend to be emotionally immature, expect a great deal of the world, require an inordinate amount of praise and appreciation, react to failure with marked feelings of hurt and inferiority, have low frustration tolerance, and feel inadequate and unsure of their abilities to fulfill expected male or female roles. Persons at high risk for developing alcohol-related problems have been found to be significantly more impulsive and aggressive than those at low risk for abusing alcohol (Morey et al.,  1984 ).

In recent years, substantial research has focused on the link between alcohol-related disorders and such other disorders as antisocial personality, depression, and schizophrenia to determine whether some individuals are more vulnerable to substance-abuse disorders. About half of the persons with schizophrenia have either alcohol or drug abuse or dependence as well (Kosten,  1997 ). By far, most of the research on comorbidity has related antisocial personality and addictive disorders, where about 75 to 80 percent of the studies have shown a strong association (Alterman,  1988 ), and conduct disorder (Slutske et al.,  1998 ). Interestingly, antisocial personality disorder, alcohol, and aggression are strongly associated (Moeller & Dougherty,  2001 ), and in a survey of eight alcohol-treatment programs, Morganstern and colleagues ( 1997 ) found that 57.9 percent of those in treatment had a personality disorder, with 22.7 percent meeting criteria for antisocial personality disorder. One study reports that substance abusers with antisocial personality disorder had lower expectations of remaining abstinent from alcohol use (Di Sclafani et al.,  2007 ).

Considerable research has suggested that there is a relationship between depressive disorders and alcohol abuse, and there may be gender differences in the association between these disorders (Kranzler et al.,  1997 ). One group of researchers (Moscato et al.,  1997 ) found the degree of association between depression and alcohol-abuse problems stronger among women.

For whatever reason they co-occur, the presence of other mental disorders in alcohol- or drug-abusing patients is a very important consideration when it comes to treatment, as will be discussed later in this chapter.

STRESS, TENSION REDUCTION, AND REINFORCEMENT

Research studies on patients undergoing substance-abusing treatment have shown high levels of trauma in their prior histories—about 25 to 50 percent of PTSD patients also have substance-abuse disorders (Schafer & Najavits,  2007 ). In one study, Deters and colleagues ( 2006 ) found that 98 percent of the American Indian adolescents in their substance-abuse study reported having a history of trauma such as threat of personal injury, witnessing of injury, or sexual abuse. One recent controlled-treatment study of disaster workers who experienced PTSD following the World Trade Center trauma (Difede et al.,  2007 ) found that excessive alcohol use was associated with dropout from treatment. Wilk and colleagues ( 2010 ) found that high exposure to threatening situations and atrocities (i.e., among Iraq war veterans) was associated with a positive screen for alcohol abuse.

A number of investigators have pointed out that the typical alcohol abuser is discontented with his or her life and is unable or unwilling to tolerate tension and stress (for example, Rutledge & Sher,  2001 ). Hussong and colleagues ( 2001 ) reported a high degree of association between alcohol consumption and negative affectivity such as anxiety and somatic complaints. In other words, alcoholics drink to relax. In this view, anyone who finds alcohol tension-reducing is in danger of abusing alcohol, even without an especially stressful life situation. However, the tension-reduction causal model is difficult to accept as a sole explanatory hypothesis. If this process were a main cause, we would expect substance-abuse disorder to be far more common than it is because alcohol tends to reduce tension for most people who use it. In addition, this model does not explain why some excessive drinkers are able to maintain control over their drinking and continue to function in society whereas others are not.

EXPECTATIONS OF SOCIAL SUCCESS

Some research has explored the idea that cognitive expectation may play an important role both in the initiation of drinking and in the maintenance of drinking behavior once the person has begun to use alcohol (see, for example, Marlatt et al.,  1998 ). Many people, especially young adolescents, expect that alcohol use will lower tension and anxiety and increase sexual desire and pleasure in life (Seto & Barbaree,  1995 ). According to the reciprocal-influence model, adolescents begin drinking as a result of expectations that using alcohol will increase their popularity and acceptance by their peers.

This view gives professionals an important and potentially powerful means of deterring drinking among young people or at least delaying its onset. From this perspective, alcohol use in teenagers can be countered by providing young people with more effective social tools and with ways of altering these expectancies before drinking begins. Smith and colleagues ( 1995 ) have suggested that prevention efforts should be targeted at children before they begin to drink so that the positive feedback cycle of reciprocal reinforcement between expectancy and drinking will never be established (see the discussion on prevention of alcohol use in  Chapter 17 ).

Time and experience do have  moderating  influences on these alcohol expectancies, although heavy drinking in early college years can result in risky behavior and low academic motivation (Hoeppner, et al.,  2012 ). In a longitudinal study of college drinking, Sher and colleagues ( 1996 ) found that there was a significant decrease in outcome expectancy over time. That is, older students showed less expectation of the benefits of alcohol than beginning students (see The World Around Us).

research CLOSE-UP: Moderating

A moderating variable is a variable that influences the association between two other variables. For example, depression is common after bereavement. However, men who have lost a spouse tend to be more likely to be depressed than women who have lost a spouse. In this case, gender is a key moderating variable for the bereavement–depression relationship.

MARITAL AND OTHER INTIMATE RELATIONSHIPS

Adults with less intimate and supportive relationships tend to show greater drinking following sadness or hostility than those with close peers and with more positive relationships (Hussong et al.,  2001 ). Excessive drinking often begins during crisis periods in marital or other intimate personal relationships, particularly crises that lead to hurt and self-devaluation. The marital relationship may actually serve to maintain the pattern of excessive drinking. (See the case study below.) Marital partners may behave toward each other in ways that promote or enable a spouse’s excessive drinking. For example, a husband who lives with a wife who abuses alcohol is often unaware of the fact that, gradually and inevitably, many of the decisions he makes every day are based on the expectation that his wife will be drinking. These expectations, in turn, may make the drinking behavior more likely. Eventually an entire marriage may center on the drinking of a substance-abusing spouse. In some instances, the husband or wife may also begin to drink excessively. Thus one important concern in many treatment programs today involves identifying the personality or lifestyle factors in a relationship that tend to foster the drinking in the alcohol-abusing person. Of course, such relationships are not restricted to marital partners but may also occur in those involved in love affairs or close friendships.

The Drunken Wife and Mother Evelyn C., a 36-year-old homemaker and mother of two school-age children (from a previous marriage), began to drink to excess especially following intense disagreements with her husband, John, a manager of a retail business. For several months, she had been drinking during the day when her children were at school and on two occasions was inebriated when they came home. On one recent occasion, Evelyn failed to pick up her older daughter after an after-school event. Her daughter called John’s cell phone (he was out of town on a business trip), and he had an assistant pick her up. When they arrived home, Evelyn (apparently unaware of the problem she had caused) created a scene and was verbally abusive toward the assistant. Her out-of-control drinking increased when her husband of 3 years began staying out all night. These emotionally charged encounters resulted in John’s physically abusing her one morning when he came back home after a night away. John moved out of the house and filed for divorce.

Excessive use of alcohol is one of the most frequent causes of divorce in the United States (Perreira & Sloan,  2001 ) and is often a hidden factor in the two most common causes—financial and sexual problems. The deterioration in interpersonal relationships of the alcohol abuser or dependent, of course, further augments the stress and disorganization in her or his life. The breakdown of marital relationships can be a highly stressful situation for many people. The stress of divorce and the often erratic adjustment period that follows can lead to increased substance abuse.

the WORLD around us: Binge Drinking in College

Two alcohol-related student deaths shocked the Colorado college community in the fall of 2004. Lynn B., an entering freshman at the University of Colorado, drank so much whiskey and wine during a fraternity initiation that he became unconscious and died as a result of alcohol poisoning. This tragic incident occurred just 2 weeks after a 19-year-old sophomore at Colorado State University, Samantha S., died of alcohol poisoning after a party at which she had consumed an estimated 40 drinks (Sink,  2004 ).

How extensive is college binge drinking? In spite of the fact that alcohol use is illegal for most undergraduates, binge drinking on campus is widespread (Rabow & Duncan-Schill,  1995 ) and increased substantially between 1998 and 2005 (Mitka,  2009 ). Sher and Rutledge ( 2007 ) reported that college students who drank in high school are likely to continue drinking during their first year in college. According to a survey by Wechsler and colleagues ( 1994 ), 44 percent of college students in the United States are binge drinkers, and Goodwin ( 1992 ) reports that 98 percent of fraternity and sorority members drink some amount every week. Some research has suggested, however, that the pattern of drinking can vary widely, with binge drinking being more of an occasional rather than a regular event (Del Boca et al.,  2004 ). Wechsler and colleagues ( 1994 ) conducted a nationwide survey of 140 college campuses in 40 states and obtained survey information pertaining to the drinking behavior and health consequences of drinking on 17,592 students (with approximately a 69 percent response rate). Students completed a 20-page survey of their drinking practices, including such information as recency of last drink, how many times they had five drinks or more in a row, and how many times they had four drinks in a row. They were also asked to provide information as to whether they experienced any of the following consequences after drinking: had a hangover, missed a class, got behind in schoolwork, did something they later regretted, forgot where they were or what they did, argued with friends, engaged in unplanned sexual activities, failed to use protection when having sex, damaged property, got into trouble with the campus police, got hurt, or required medical treatment for an alcohol overdose.

The colleges surveyed in the study varied widely in the extent of binge drinking among the student body. As one might expect—some colleges earn reputations as being “party schools”—some institutions had a large number of students (70 percent) heavily involved in alcohol and binge drinking, but the problem occurred to some degree across most college campuses. Recent research has suggested that heavier drinking students may self-select into certain study abroad programs with specific intentions to use alcohol (Pedersen et al.  2010 ).

What are the reasons for the widespread problem of binge drinking in college? Many factors can be cited, such as students’ expressing independence from parental influence (Turrisi et al.,  2000 ); peer group and situational influences (Read et al.,  2003 ); developing and asserting gender roles, particularly for men adopting a “macho” role (Capraro,  2000 ); and holding beliefs that alcohol can help make positive transformations, such as “having a few drinks to celebrate special occasions” (Turrisi,  1999 ). One recent study suggested that a family history of alcohol abuse was associated with problematic drinking among college students (LaBrie, et al.  2010 ).

The consequences of college binge drinking can be far-reaching and often involve disinhibited behavior (Carlson et al.,  2010 ). In their survey, Wechsler and colleagues ( 1994 ) reported a strong association between the frequency of binge drinking and alcohol-related health and life problems. In fact, binge drinkers were nearly 10 times more likely than those who did not indulge in binge drinking to engage in unplanned sexual activity, not to use protection when having sex, to get into trouble with campus police, to damage property, and to get hurt after drinking. Men and women tended to report similar problems, except that men engaged in more property damage than women. Over 16 percent of the men and 9 percent of the women reported having gotten into trouble with the campus police. About 47 percent of the frequent binge drinkers, compared with 14 percent of the non–binge drinkers, indicated that they had experienced five or more of the problems surveyed. In a more recent follow-up survey of college drinking in 1997, Wechsler and colleagues ( 1998 ) reported strikingly similar results.

One recent study suggests that extensive drinking in college, even among the heaviest drinkers from sororities and fraternities, might be determined to a great extent by situational events, factors that change with graduation. In a follow-up study of drinking behavior a year after graduation, Sher, Bartholow, and Nanda ( 2001 ) reported that being a member of a fraternity or sorority did not predict postcollege drinking. Interestingly, a long-term follow-up of over 11 years has shown that the heavy drinking during college did not translate to heavy drinking during later years (Bartholow et al.,  2003 ). These investigators found that heavy drinking that is associated with Greek society involvement does not generally lead to sustained heavy drinking in later life.

Some institutions provide a psychological intervention in an effort to reduce the extent of drinking among college students. One recent study reported that a procedure referred to as Brief Motivational Intervention, or BMI, produced greater self-regulation among a sample of binging college students by providing skills for them to moderate their drinking behavior (Carey et al.,  2007 ). This procedure was more effective among students who also showed, in their pretreatment assessment, a readiness to change.

Family relationship problems have also been found to be central to the development of alcoholism (Dooley & Prause,  2007 ). In a classic longitudinal study of possible etiologic factors in alcohol abuse, Vaillant and colleagues ( 1982 ) described six family relationship factors that were significantly associated with the development of alcoholism in the individuals they studied. The most important family variables that were considered to pre-dispose an individual to substance-use problems were the presence of an alcoholic father, acute marital conflict, lax maternal supervision and inconsistent discipline, many moves during the family’s early years, lack of “attachment” to the father, and lack of family cohesiveness.

Sociocultural Causal Factors

Alcohol use is a pervasive component in the social life in Western civilization. Social events often revolve around alcohol use, and alcohol use before and during meals is commonplace. Alcohol is often seen as a “social lubricant” or tension reducer that enhances social events. Thus investigators have pointed to the role of sociocultural as well as biological and psychological factors in the high rate of alcohol abuse and dependence among Americans.

The effect of cultural attitudes toward drinking is well illustrated by Muslims and Mormons, whose religious values prohibit the use of alcohol, and by orthodox Jews, who have traditionally limited its use largely to religious rituals. The incidence of alcoholism among these groups is minimal. In comparison, the incidence of alcoholism is high among Europeans. For example, one survey showed the highest alcohol-use rates among young people to be in Denmark and Malta, where one in five students reported having drunk alcohol 10 times within the past 30 days (ESPAD,  2000 ). Interestingly, Europe and six countries that have been influenced by European culture—Argentina, Canada, Chile, Japan, the United States, and New Zealand—make up less than 20 percent of the world’s population and yet consume 80 percent of the alcohol (Barry,  1982 ). Alcohol abuse continues to be a problem in Europe by, for example, contributing to accidents (Lehto,  1995 ), crime (Rittson,  1995 ), liver disease (Medical Council on Alcoholism,  1997 ), and the extent to which young people are developing substance-use problems (Anderson & Lehto,  1995 ). The French appear to have the highest rate of alcoholism in the world, involving approximately 15 percent of the population. France has both the highest per capita alcohol consumption and one of the highest death rates from cirrhosis of the liver (Noble,  1979 ). In addition, France shows the highest prevalence rates: In a broad survey of hospital patients, 18 percent (25 percent for men and 7 percent for women) were reported to have alcohol-use disorders even though only 6 percent of admissions were for alcohol problems (Reynaud et al.,  1997 ). In Sweden, another country with high rates of alcoholism, 13.2 percent of men’s hospital admissions, and 1.1 percent of women’s, are attributed to alcohol (Andreasson & Brandt,  1997 ). Thus it appears that religious sanctions and social customs can influence whether alcohol is one of the coping methods commonly used in a given group or society.

The behavior that is manifested under the influence of alcohol also seems to be influenced by cultural factors. Lindman and Lang ( 1994 ), in a study of alcohol-related behavior in eight countries, found that most people expressed the view that aggressive behavior frequently follows their drinking “many” drinks. However, the expectation that alcohol leads to aggression is related to cultural traditions and early exposure to violent or aggressive behavior.

In sum, we can identify many reasons why people drink—as well as many conditions that can predispose them to do so and reinforce their drinking behavior—but the exact combination of factors that results in a person’s becoming an alcoholic is still unknown.

Treatment of Alcohol-Related Disorders

Alcohol abuse and dependence are difficult to treat because many alcohol abusers refuse to admit that they have a problem before they “hit bottom,” and many who do go into treatment leave before therapy is completed. DiClemente ( 1993 ) refers to the addictions as “diseases of denial.” However, in a review of several large alcohol-treatment studies, Miller, Walters, and Bennett ( 2001 ) reported that two-thirds of studies show large and significant decreases in drinking and related problems. In this section, we will examine both biological and psychosocial treatment strategies. Some treatment approaches appear to reduce drinking-related problems more effectively than others (Miller & Wilbourne,  2002 ; Zweben,  2001 ). In general, a multidisciplinary approach to the treatment of drinking problems appears to be most effective because the problems are often complex, requiring flexibility and individualization of treatment procedures (Margolis & Zweben,  1998 ). Also, a substance abuser’s needs change as treatment progresses. Treatment objectives usually include detoxification, physical rehabilitation, control over alcohol-abuse behavior, and the individual’s realizing that he or she can cope with the problems of living and lead a much more rewarding life without alcohol.

Traditional treatment programs usually have as their goal abstinence from alcohol (Ambrogne,  2002 ). However, some programs attempt to promote controlled drinking as a treatment goal for problem drinkers. For example, one procedure referred to as Brief Motivational Intervention attempts to modify clients’ behavior through providing information and advice about the consequences of the substance use in an effort to challenge the users about their use—but leaves the responsibility to the individual (Carey et al.,  2007 ; Miller & Rollnik,  2002 ; Peterson et al.,  2006 ). No matter what the treatment method, relapse is common, and many in the field see relapse as a factor that must be addressed in the treatment and recovery process.

USE OF MEDICATIONS IN TREATING ALCOHOL ABUSE AND DEPENDENCY

Biological approaches include a variety of treatment measures such as medications to reduce cravings, to ease the detoxification process, and to treat co-occurring health (National Institutes of Health,  2001 ) and mental health problems that may underlie the drinking behavior.

Medications to Block the Desire to Drink Disulfiram (Antabuse), a drug that causes violent vomiting when followed by ingestion of alcohol, may be administered to prevent an immediate return to drinking (Grossman & Ruiz,  2004 ). However, such deterrent therapy is seldom advocated as the sole approach because pharmacological methods alone have not proved effective in treating many severe alcohol-abuse problems (Gorlick,  1993 ). For example, because the drug is usually self-administered, an alcohol-dependent person may simply discontinue the use of Antabuse when he or she is released from a hospital or clinic and begins to drink again. In fact, the primary value of drugs of this type seems to be their ability to interrupt the alcohol-abuse cycle for a period of time during which therapy may be undertaken. Uncomfortable side effects may accompany the use of Antabuse; for example, alcohol-based aftershave lotion can be absorbed through the skin, resulting in illness. Moreover, the cost of Antabuse treatment, which requires careful medical maintenance, is higher than that for many other, more effective treatments.

Another type of medication that has been used in a promising line of research (Kranzler et al.,  2004 ) is naltrexone, an opiate antagonist that helps reduce the craving for alcohol by blocking the pleasure-producing effects of alcohol (Gueorguieva et al.,  2007 ; Lee et al.,  2010 ). O’Malley and colleagues ( 1996 ) have shown that naltrexone reduced the alcohol intake and lowered the incentive to drink for alcohol abusers compared with a control sample given a placebo. Some research has suggested that naltrexone is particularly effective with individuals who have a high level of craving (Monterosso et al.,  2001 ) and show effects of binge drinking (Johnson,  2010 ). Other research, however, has failed to find naltrexone effective at reducing craving (Krystal et al.,  2001 ), so confidence in its use for this purpose must await further research.

Medications to Reduce the Side Effects of Acute Withdrawal In cases of acute intoxication, the initial focus is on detoxification (the elimination of alcoholic substances from an individual’s body), on treatment of the withdrawal symptoms described earlier, and on a medical regimen for physical rehabilitation. One of the primary goals in treatment of withdrawal symptoms is to reduce the physical symptoms characteristic of withdrawal such as insomnia, headache, gastrointestinal distress, and tremulousness. Central to the medical treatment approaches are the prevention of heart arrhythmias, seizures, delirium, and death. These steps can usually best be handled in a hospital or clinic, where drugs such as Valium have largely revolutionized the treatment of withdrawal symptoms. Such drugs overcome motor excitement, nausea, and vomiting; prevent withdrawal delirium and convulsions; and help alleviate the tension and anxiety associated with withdrawal. Pharmacological treatments with long-lasting benzodiazepines, such as diazepam, to reduce the severity of withdrawal symptoms have been shown to be effective (Malcolm,  2003 ).

Concern is growing, however, that the use of tranquilizers—drugs that depress the CNS, resulting in calmness, relaxation, reduction of anxiety, and sleeping—does not promote long-term recovery and may simply transfer the addiction to another substance. Accordingly, some detoxification clinics are exploring alternative approaches including a gradual weaning from alcohol instead of a sudden cutoff. Maintenance doses of mild tranquilizers are sometimes given to patients withdrawing from alcohol to reduce anxiety and help them sleep. Such use of medications may be less effective than no treatment at all, however. Usually patients must learn to abstain from tranquilizers as well as from alcohol because they tend to misuse both. Further, under the influence of medications, patients may even return to alcohol use.

PSYCHOLOGICAL TREATMENT APPROACHES

Once the patient has her or his drinking under control, detoxification is optimally followed by psychological treatment, including family counseling and the use of community resources related to employment and other aspects of a person’s social readjustment. Although individual psychotherapy is sometimes effective, the focus of psychosocial measures in the treatment of alcohol-related problems often involves group therapy, environmental intervention, behavior therapy, and the approach used by Alcoholics Anonymous and family groups such as Al-Anon and Alateen.

Group Therapy  Group therapy has been shown to be effective for many clinical problems (Galanter et al.,  2005 ), especially substance-related disorders (Velasquez et al.,  2001 ). In the confrontational give-and-take of group therapy, alcohol abusers are often forced (perhaps for the first time) to face their problems and their tendencies to deny or minimize them. These group situations can be extremely difficult for those who have been engrossed in denial of their own responsibilities, but such treatment also helps them see new possibilities for coping with circumstances that have led to their difficulties. Often this paves the way for them to learn more effective ways of coping and other positive steps toward dealing with their drinking problem.

In some instances, the spouses of alcohol abusers and even their children may be invited to join in group therapy meetings. In other situations, family treatment is itself the central focus of therapeutic efforts. In that case, the alcohol abuser is seen as a member of a disturbed family in which all members have a responsibility for cooperating in treatment. Because family members are frequently the people most victimized by the alcohol abuser’s addiction, they often tend to be judgmental and punitive, and the person in treatment, who has already passed harsh judgment on himself or herself, may tolerate this further source of devaluation poorly. In other instances, family members may unwittingly encourage an alcohol abuser to remain addicted—for example, a man with a need to dominate his wife may find that a continually drunken and remorseful spouse best meets his needs.

Environmental Intervention As with other serious mal-adaptive behaviors, a total treatment program for alcohol abuse or dependency usually requires measures to alleviate a patient’s aversive life situation. Environmental support has been shown to be an important ingredient of an alcohol abuser’s recovery. People often become estranged from family and friends because of their drinking and either lose or jeopardize their jobs. As a result, they are often lonely and live in impoverished neighborhoods. Typically, the reaction of those around them is not as understanding or as supportive as it would be if the alcohol abuser had a physical illness of comparable magnitude. Simply helping people with alcohol-abuse problems learn more effective coping techniques may not be enough if their social environment remains hostile and threatening. For those who have been hospitalized, halfway houses—designed to assist them in their return to family and community—are often important adjuncts to their total treatment program.

Behavioral and Cognitive-Behavioral Therapy  An interesting and often effective form of treatment for alcohol-related disorders is behavioral therapy, of which several types exist. One is aversive conditioning therapy, which involves the presentation of a wide range of noxious stimuli with alcohol consumption in order to suppress drinking behavior. For example, the ingestion of alcohol might be paired with an electric shock or a drug that produces nausea. A variety of pharmacological and other deterrent measures can be used in behavioral therapy after detoxification. One approach involves an intramuscular injection of emetine hydrochloride, an emetic. Before experiencing the nausea that results from the injection, a patient is given alcohol, so that the sight, smell, and taste of the beverage become associated with severe retching and vomiting. That is, a conditioned aversion to the taste and smell of alcohol develops. With repetition, this classical conditioning procedure acts as a strong deterrent to further drinking—probably in part because it adds an immediate and unpleasant physiological consequence to the more general socially aversive consequences of excessive drinking.

One of the most effective contemporary procedures for treating alcohol abusers has been the cognitive-behavioral approach recommended by Alan Marlatt ( 1985 ) and Witkiewitz and Marlatt ( 2004 ). This approach combines cognitive-behavioral strategies of intervention with social-learning theory and modeling of behavior. The approach, often referred to as a “skills training procedure,” is usually aimed at younger problem drinkers who are considered to be at risk for developing more severe drinking problems because of an alcohol-abuse history in their family or their current heavy consumption. This approach relies on such techniques as imparting specific knowledge about alcohol, developing coping skills in situations associated with increased risk of alcohol use, modifying cognitions and expectancies, acquiring stress-management skills, and providing training in life skills (Connors & Walitzer,  2001 ). Cognitive-behavioral treatments have been shown to be effective; for example, O’Farrell and colleagues ( 2004 ) report that partner violence was significantly reduced following cognitive-behavioral treatment.

Self-control training techniques, such as the Brief Motivational Intervention noted earlier, in which the goal of therapy is to get alcoholics to reduce alcohol intake without necessarily abstaining altogether, have a great deal of appeal for some drinkers. For example, one recent approach to improve drinking outcomes by altering the drinker’s social networks was found to be successful (Litt et al.,  2007 ) and motivational interviewing with adolescents was found to be promising (Macgowan & Engle,  2010 ). There is now even a computer-based self-control training program available that has been shown to reduce problem drinking in a controlled study (Fals-Stewart & Lam,  2010 ; Neighbors et al.,  2004 ). It is difficult, of course, for individuals who are extremely dependent on the effects of alcohol to abstain totally from drinking. Thus many alcoholics fail to complete traditional treatment programs.

CONTROLLED DRINKING VERSUS ABSTINENCE

Other psychological techniques have also received attention in recent years, partly because they are based on the hypothesis that some problem drinkers need not give up drinking altogether but rather can learn to drink moderately (Miller, Walters, & Bennett,  2001 ; Sobell & Sobell,  1995 ). Several approaches to learning controlled drinking have been attempted (McMurran & Hollin,  1993 ), and research has suggested that some alcoholics can learn to control their alcohol intake (Senft et al.,  1997 ). Miller and colleagues ( 1986 ) evaluated the results of four long-term follow-up studies of controlled-drinking treatment programs. Although they found a clear trend of increased numbers of abstainers and relapsed cases at long-term follow-up, they also found that a consistent percentage (15 percent) of subjects across the four studies controlled their drinking. The researchers concluded that controlled drinking was more likely to be successful in persons with less severe alcohol problems. The finding that some individuals are able to maintain some control over their drinking after treatment (without remaining totally abstinent) was also reported in a classic study by Polich et al. ( 1981 ). These researchers found that 18 percent of the alcoholics they studied had reportedly been able to drink socially without problems during the 6-month follow-up of treatment.

Many people in the field have rejected the idea that alcohol abusers can learn to control their drinking, and some recent research has found that controlled drinking is not effective (Bottlender et al.,  2007 ). And some groups, such as Alcoholics Anonymous, are adamant in their opposition to programs aimed at controlled drinking for alcohol-dependent individuals.

ALCOHOLICS ANONYMOUS

A practical approach to alcoholism that has reportedly met with considerable success is that of Alcoholics Anonymous (AA). This organization was started in 1935 by two men, Dr. Bob and Bill W., in Akron, Ohio. Bill W. recovered from alcoholism through a “fundamental spiritual change” and immediately sought out Dr. Bob, who, with Bill’s assistance, also achieved recovery. They in turn began to help other alcoholics. Since that time, AA has grown to over 52,000 groups in the United States, with an annual growth rate of about 6 to 7 percent (Alcoholics Anonymous,  2007 ). In addition, there are nearly 5,000 AA groups in Canada and over 45,000 groups in many other countries.

Alcoholics Anonymous operates primarily as a self-help counseling program in which both person-to-person and group relationships are emphasized. AA accepts both teenagers and adults with drinking problems, has no dues or fees, does not keep records or case histories, does not participate in political causes, and is not affiliated with any religious sect, although spiritual development is a key aspect of its treatment approach. To ensure anonymity, only first names are used. Meetings are devoted partly to social activities, but they consist mainly of discussions of the participants’ problems with alcohol, often with testimonials from those who have stopped drinking. Such members usually contrast their lives before they broke their alcohol dependence with the lives they now live without alcohol. We should point out here that the term alcoholic is used by AA and its affiliates to refer either to persons who currently are drinking excessively or to people who have stopped drinking but must, according to AA philosophy, continue to abstain from alcohol consumption in the future. That is, in the AA view, one is an alcoholic for life, whether or not one is drinking; one is never “cured” of alcoholism but is instead “in recovery.”

An important aspect of AA’s rehabilitation program is that it appears to lift the burden of personal responsibility by helping alcoholics accept that alcoholism, like many other problems, is bigger than they are. Henceforth, they can see themselves not as weak willed or lacking in moral strength but rather simply as having an affliction—they cannot drink—just as other people may not be able to tolerate certain types of medication. Through mutual help and reassurance from group members who have had similar experiences, many alcoholics acquire insight into their problems, a new sense of purpose, greater ego strength, and more effective coping techniques. Continued participation in the group, of course, can help prevent the crisis of a relapse. Affiliated movements such as Al-Anon family groups and Ala-teen (which has over 35,000 groups in the United States and Canada) are designed to bring family members together to share experiences and problems, to gain understanding of the nature of alcoholism, and to learn techniques for dealing with their own problems living in a family with one or more affected individuals.

The reported success of Alcoholics Anonymous is based primarily on anecdotal information rather than on objective study of treatment outcomes because AA does not directly participate in external comparative research efforts. However, several studies have found AA conditions effective in helping people avoid drinking (Kelly, Stout et al.,  2010 ). In a classic study, Brandsma and colleagues ( 1980 ) included an AA program in their extensive comparative study of alcoholism treatments. The success of this treatment method with severe alcoholics was found to be quite limited. Another important finding was that the AA method had high dropout rates compared with other therapies. About half of the people who go to AA drop out of the program within 3 months. Chappel ( 1993 ) attributes the very high dropout rate to alcoholics’ denial that they have problems, resistance to external pressure, and resistance to AA itself. Apparently many alcoholics are unable to accept the quasireligious quality of the sessions and the group-testimonial format that is so much a part of the AA program. In the Brandsma study, the participants who were assigned to the AA group subsequently encountered more life difficulties and drank more than the people in the other treatment groups. On the positive side, however, a study by Morganstern and colleagues ( 1997 ) reports that affiliation with AA after alcohol treatment was associated with better outcomes than without such involvement, and a study by Tonigan and colleagues ( 1995 ) found that AA involvement was strongly associated with success in outpatient samples.

image11

These people are participating in an Alcoholics Anonymous (AA) meeting. AA accepts both teenagers and adul

Place this order or similar order and get an amazing discount. USE Discount code “GET20” for 20% discount