Alcohol addictionAlcohol addiction is the most common addictive disease in Germany. However, not only people with manifest alcohol dependence are at risk of damage to health and negative psychosocial consequences of alcohol consumption, but also the so-called risk drinkers. However, the alcohol problems are often negated.
Anyone who regularly looks too deeply into the glass accepts long-term damage to health. Photo: a4+/F1online
Germany is slightly above the EU average in alcohol consumption. The number of people in need of treatment is high. Source: Hering Schuppener
With regular excessive alcohol consumption, various organ systems are damaged. Photo: zm/Meinardus
"No one can refuse a glass in honor" – this "folk wisdom" is passe: because around 1.4 million people in this country are addicted to alcohol, and a further two million have harmful alcohol consumption. In addition, there are 9.5 million people with at-risk alcohol use. They cannot (yet) be diagnosed with alcohol dependence, but are at risk of or already affected by serious physical illnesses such as liver damage caused by alcohol consumption, or by social consequences such as the alcohol-related loss of their driver's license. Thus, in total, about 13 million people in Germany have an alcohol problem.
The numbers make it clear that alcohol is a serious health risk factor in our society. Alcohol dependence is the most common addictive disease in Germany. However, this is still largely negated, which explains why only around nine percent of those affected are actually in treatment. The fact that the dangers of alcohol consumption are not recognized in large parts of the population is also shown by the high average per capita consumption/anno of pure alcohol of 10.5 liters in Germany, which is in the upper range in an international comparison.
Definition of alcohol dependence
Alcohol dependence as a psychiatric disease is to be amed in the case of a strong, sometimes overpowering desire to consume alcohol, a narrowing of thinking and interests to alcohol consumption as well as a reduced control over the amount of alcohol drunk, according to an information leaflet of the "Deutsche Hauptstelle fur Suchtfragen e.V." (DHS). There is a psychological dependence in those affected, which often develops imperceptibly. Often, moreover, tolerance development and withdrawal symptoms occur when alcohol consumption is reduced, as an expression of physical dependence.
According to the ICD-10 classification, alcohol dependence is diagnosed if at least three of the following criteria have been met in the past twelve months:
– Craving (uncontrollable desire for alcohol)
– Loss of control over alcohol consumption in terms of onset or amount
– Physical withdrawal syndrome when reducing the amount of alcohol consumed
– Development of tolerance to the effects of alcohol
– Narrowing in on substance use and thereby neglecting other interests
– continued alcohol consumption despite clearly harmful consequences (health-related, psychological or social)
Harmful alcohol consumption or alcohol abuse can be amed when alcohol is consumed habitually in large quantities in order to experience the positive effects, but without an overpowering compulsive desire or compulsion to consume. Risky alcohol consumption is when quantities of alcohol are consumed that usually lead to the expectation of the development of diseases.
Resorption and degradation
The absorption and metabolization of alcohol in the body varies somewhat from person to person. In most individuals, maximum blood levels are reached within 75 minutes of alcohol ingestion, with women developing levels about 25 percent higher on average than men for the same alcohol intake due to differences in volume of distribution. However, alcohol is usually eliminated from the bloodstream more quickly in women.
90 to 95 percent of metabolism takes place in the liver, with small amounts also occurring in the mucous membrane of the stomach and small intestine. The main enzyme responsible for alcohol degradation is alcohol dehydrogenase (ADH).
Development of dependence
The effect of alcohol is essentially due to an increase in the inhibitory effect of the neurotransmitter gamma-amino-butyric acid (GABA) in the brain. Alcohol also has inhibitory effects on glutami-nergic signaling, and chronic alcohol consumption upregulates NMDA receptors in the brain. Other neurotransmitter systems such as the serotonergic system and the endorphins, i.e. the body's own opioids, also change under the influence of alcohol.
Overall, alcohol has anxiolytic, sedative and hypnogenic effects due to the changes in brain metabolism, although the effects can also vary in their expression and intensity from person to person.
The development of alcohol dependence is due to the interaction of the specific substance effects of alcohol described above, coupled with biological factors of the individual person as well as psychological factors and the influence of the sociocultural environment.
Risk categories in alcohol consumption
The World Health Organization (WHO) has formulated risk categories for daily alcohol consumption:
– Accordingly, a low risk exists for women with an average alcohol consumption of up to 20 grams daily, for men up to 40 grams daily.
– A medium risk can be amed for a daily alcohol consumption of 20 to 40 grams for women and 40 to 60 grams for men.
– A high risk is given by a daily consumption of 40 to 60 grams of alcohol in women and 60 to 100 grams in men.
– A very high risk exists if the daily alcohol consumption exceeds an average of 60 grams for women and 100 grams for men.
In concrete terms, this means that with a regular consumption of two to three glasses of wine per day – which corresponds to 40 to 60 grams of alcohol – a high health risk can already be amed in women.
Alcohol as a risk factor
Regular high alcohol consumption leads to damage to a wide variety of organs, starting with the liver and including the heart and brain. Alcohol is thus a risk factor for a whole bundle of different diseases. Approximately 30 diseases are seen to be directly related to alcohol, and 60 diseases have an association. Among other things, this includes psychiatric disorders such as depression, delusional and anxiety disorders, gastrointestinal disorders such as reflux esophagitis and gastritis, pancreatic disorders, alcohol-induced osteopathy and, of course, the dependence syndrome with corresponding behavioral abnormalities and also cognitive consequences.
However, alcohol dependence is associated not only with increased morbidity, but also with increased mortality: It is estimated that around 73,000 deaths per year in this country are attributable to alcohol as well as the overlap area of high alcohol and tobacco consumption: One in eight deaths among men and one in 14. Deaths in women between the ages of 15 and 64 are at least partly caused by risky alcohol consumption.
In addition, according to the DHS, around 238,000 crimes are committed under the influence of alcohol each year in Germany, which accounts for around seven percent of all crimes. Alcohol is involved in around 33,000 traffic accidents, or around nine percent, and around 1,500 people die each year in Germany as a result of traffic accidents involving alcohol. In addition, about 2,200 children are born each year with alcohol embryopathy.
Alcohol and liver
The damaging effect of alcohol on the liver is well known, with acute, alcohol-induced liver damage developing into cirrhosis via alcohol-induced fatty liver and alcoholic steato-hepatitis (ASH). Once ASH is present, the prognosis is considerably limited. If abstinence is achieved, the seven-year survival rate is about 80 percent.
With continued alcohol consumption, however, 40 percent of those affected develop cirrhosis of the liver, and curative therapy is then no longer possible. However, even with alcohol abstinence, liver cirrhosis develops in around 20 percent of ASH patients in the further course of their disease. There is also a significantly increased risk of hepatocellular carcinoma.
Alcohol and cancer
It is also documented that alcohol increases the risk of cancer of the mouth and pharynx, larynx and esophagus, with an apparent direct dose dependence. Thus, the higher the alcohol consumption, the higher the risk of cancer in these entities. Also in colorectal carcinoma, liver as well as pancreatic carcinoma and even breast carcinoma is seen to be related to alcohol consumption. It is estimated that about ten percent of cancers in men and three percent in women are triggered by alcohol.
However, these figures are subject to certain uncertainties. Above all, it is difficult to determine whether people with low and moderate alcohol consumption actually have an increased risk of cancer. This is due to the fact that heavy drinkers often report a much lower alcohol consumption in interviews than they do in reality. When evaluating the data, however, the impression then arises that a higher cancer risk of the person surveyed is based on low or moderate alcohol consumption. This was pointed out at this year's European Cancer Congress in Vienna. "When many heavy drinkers report drinking only a little, the effects of heavy drinking are erroneously transferred to low to fashionable alcohol consumption," explained there Dr. Arthur Klatsky from Oakland/USA.
Abstinence as a treatment goal
The goal of treatment for alcohol dependence is clearly abstinence. However, this goal is notoriously difficult to achieve. Clearly stating abstinence as a treatment goal may even be a barrier to starting treatment at all for many affected individuals. Increasingly, therefore, the first step is to try to reduce the alcohol consumption of those affected, at least sustainably, in order to pave the way, if possible, to complete abstinence.
Experts like Prof. Dr. Joachim Korkel of the "Institute for Innovative Addiction Treatment and Addiction Research", Nuremberg, therefore advocates treating alcohol addicts in a goal-oriented manner, i.e. openly and without sanctions agreeing with them on their future consumption intentions and offering them treatment that is appropriate to their goals.
In concrete terms, this means that abstinence treatment should be given to patients who are motivated or can be motivated accordingly. However, for people who are not able or motivated to abstinence treatment, Korkel believes that it should be possible to provide treatment that aims to at least reduce alcohol consumption and to do so as sustainably as possible. The addiction researcher's experience is that such an open-target approach can ultimately persuade more people to change their drinking behavior.
A compromise is controlled drinking
Behavioral reduction programs such as (self-)controlled drinking, in which the patient learns to adjust his or her alcohol consumption to self-determined upper limits, are then used to reduce alcohol consumption. "Pragmatically, this means that the individual determines and tries to adhere to his or her maximum daily or maximum weekly drinking amount and number of alcohol-free days for one week in advance at a time," Korkel says.
According to his data, success rates of 65 percent on average can be achieved with the help of such behavioral therapy programs, which is roughly equivalent to the success rate of abstinence programs. It is not uncommon for controlled drinking to be maintained for years. According to Korkel, for ten to even 30 percent of patients, it is also the entry into a later abstinence treatment.
Behavioral therapy can be supported by agents such as nalmefene, which modulate the opioid system in the brain, thereby reducing alcohol craving.
Studies have shown that taking the substance reduces the number of heavy drinking days (HDD) and total alcohol consumption (TAC) by 65 percent.
Prediction: risk of relapse genetically predetermined
Magnetic resonance imaging (MRI) of the brain may be able to predict whether alcohol addicts will remain abstinent or relapse after alcohol detoxification. Scientists at Charite University Medicine in Berlin have been able to show that patients who relapse obviously have structural as well as functional abnormalities in the brain. The researchers studied a group of 46 alhocoholics after abstinence treatment and an equally sized control group, and repeated imaging after three months. At this point, 16 study participants remained abstinent, and 30 had relapsed. Relapse patients were found to have increased gray matter loss in the forebrain, in specific brain regions associated with behavioral regulation and emotion control.
The measurement of electrical signals also revealed that different brain regions become active in response to alcohol-associated stimuli in relapse patients than in study participants who remain abstinent. In particular, brain regions primarily associated with attention control respond. In contrast, in patients who remain abstinent, regions of the brain become active that are associated with processing stimuli that evoke aversion, among other things. "These features in the patients who remained abstinent may act as a warning signal and prevent potential relapse when confronted with alcohol," comments study leader Dr. Anne Beck the result.
Future studies will also examine whether genetic mechanisms determine the observed changes in the brain. The scientists hope to be able to identify people at particular risk of relapse on the basis of such studies and to provide them with targeted therapeutic support.
From the point of view of dentistry
According to the report of the World Health Organization (WHO), alcoholism is the psychiatric disease with the highest prevalence worldwide. It is associated overall with a significant increase in multi- pler associated symptoms, ranging from social foreclosure to manifest cancer. Harmful alcohol use therefore has a high health and socio-political relevance. However, it is very often downplayed and trivialized or even denied by those affected and their personal environment (co-dependency).
Early detection of alcohol-endangered and -ill people, before pronounced physical consequential damages and further psychosocial alcohol-related problems develop, is of great importance. Especially when alcohol is initially consumed to relieve anxiety and stress and thus, often unnoticed and socially accepted for a long time, habituation and dependence develop. Adequate diagnosis and treatment of mental illness must be considered alongside addiction treatment in these patients.
It can be amed that at least two thirds of all adults visit a dentist at least once a year. This individual will perform a rapid screening examination on his patients regarding oral cancer as part of routine clinical practice in the best case scenario. Besides tobacco abuse and poor oral hygiene, alcohol abuse is a crucial risk factor. However, compared to hygiene and smoking, hardly any prevention and intervention approaches exist at present. In a 2006 study by Miller and colleagues, 75 percent of respondents agreed that screening for alcohol and counseling on this topic at the time of a dental visit would be useful. An important prerequisite of such an examination is that it is a temporally short intervention – perhaps also by the assisting staff. Increased (quantity and frequency) alcohol consumption must be inquired about, but without being condemning. At the top of the list should be empathy. Motivation without argumentation or confrontation.
Patients with alcohol abuse should also be made aware of the qualitative and quantitative discrepancy with the general population. In addition, forms with guideline values can be handed out, for example. Patients must be informed above all that the risk of developing cancer in the oral cavity is increased many times over in alcohol consumers, even if no direct correlation can be made between quantity and risk.
It seems quite possible, even in the dental practice, to ask patients about their alcohol consumption in an intervention lasting three to five minutes, to educate them and to motivate them to abstinence, especially if preliminary stages of oral mucosal changes are already recognizable.
Univ.-Prof. Dr. Dr. Monika Daublander Senior Physician, Department of Dental Surgery University Medical Center, Johannes Gutenberg University Mainz Department of Dental Surgery Augustusplatz 2 55131 Mainz [email protected]
Dr. Dr. Peer W.