ALCOHOL
Melisse Leung, Premedical Student
University of California, Berkeley

ROUTE OF ADMINISTRATION

The route of alcohol consumption is through the mouth. Alcohol enters the blood primarily from the small intestine. Only about 20% of the alcohol passes through the lining of the stomach and into the bloodstream. Once alcohol is absorbed into the bloodstream, it is rapidly circulated throughout the body. Alcohol is bound to water through hydrogen bonding. The attraction between water and the hydroxyl group of the alcohol molecules is strong enough to solubilize alcohol, but not so strong that alcohol is irrevocably bound to water. In order to enter brain cells and cells of other body tissues, alcohol must be able to "escape" from water in order to enter other substances that form the lining of the blood vessels and the walls of nerve cells.

The alcohol molecule is unique in the ease with which it can enter nerve cells and return to the blood. The unique hydrophilic qualities of alcohol make it a perfect molecule for rapid entry into and exit from the brain. The passage of most other substances into the brain is prevented by the blood-brain barrier, the physiological system composed of barriers formed by the cells that line the interior of the blood vessel, and those that comprise the walls of the nerve cell. This blood-brain barrier actively prevents the entry of certain substances, particularly large molecules, into the brain so that potentially harmful compounds do not reach the cells of the brain. The lipid solubility of alcohol permits alcohol to enter, but the forces that attract alcohol to lipid molecules are not powerful enough to permanently entrap the alcohol molecule in the lipid phase. This is extremely important because if alcohol were held or trapped in the lipids that constitute cell walls, it could not diffuse into water on its way to and from the nerve cell.

ALCOHOL ABSORPTION

A number of factors in the body and in the nature of the alcohol beverage itself may retard or accelerate the transport of alcohol into the bloodstream. The presence or absence of food in the stomach is one critical determinant of the rate of alcohol absorption. Before alcohol can be absorbed into the bloodstream it must enter the small intestine from the stomach. Passage from the stomach into the small intestine is controlled by the muscular pyloric valve, which remains closed until food in the stomach has been acted upon by acids and enzymes secreted by the stomach wall. If alcohol is ingested with food, it will take longer for the alcohol to reach the small intestine because the pyloric valve will remain closed. This is the basis of the well-known fact that eating while drinking slows down the rate of absorption of alcohol.

On the contrary, if alcohol is consumed when the stomach is empty, it may be emptied into the small intestine very rapidly. The optimal alcohol concentration to facilitate rapid stomach-emptying corresponds to that of distilled spirits, 86 proof or 43 percent alcohol. This concentration of alcohol passes most readily from the stomach into the small intestine, where it is absorbed into the bloodstream. However, if too much alcohol is consumed too rapidly, resulting in a high concentration of alcohol in an empty stomach, the pyloric valve may go into spasm. Under these conditions, vomiting usually occurs and alcohol does not enter the intestinal tract. This is one of the body's many protective devices to prevent toxic substances from leaving the stomach and entering the intestinal tract and the bloodstream.

Another factor that facilitates the absorption of alcohol from the small intestine is whether the beverage mixer consumed with the alcohol, or the alcohol itself, is carbonated or not. Carbonated beverages are absorbed more readily than noncarbonated beverages. The rapid intoxication produced by champagne, in contrast to a noncarbonated wine with an equivalent alcohol concentration, is due to the fact that champagne is carbonated. The rate of alcohol absorption from the small intestine is also influenced by the congener content of the beverage. Congeners are substances (complex organic molecules) that may be added to alcohol or evolve through the process of fermentation and aging. Low congener beverages, such as vodka, are absorbed more rapidly than high congener beverages, such as brandy. Food in the stomach, carbonation of the alcohol beverage, the congener content, and the concentration of the beverage alcohol all combine to affect the rate at which alcohol is absorbed from the small intestine and consequently the blood alcohol level at any point in time.

One important factor that contributes to the unpredictability of blood alcohol levels is the difference in the concentration of protein, lipids (fats), and water in the human body. Although alcohol is readily soluble in fat, it is more soluble in water. Persons who have relatively large amounts of body fat will have higher blood alcohol levels than lean individuals after drinking the same amount of alcohol. Because females usually have a higher proportion of fat in their bodies than males, the popular notion that females tend to become more intoxicated than males after drinking approximately the same amounts of alcohol is often true. The level of intoxication is a direct function of the concentration of alcohol in the blood. Alcohol remains in the body for a finite period. The absorption peak effect, and decay of alcohol concentrations in the blood form a curve through time. The rate of alcohol disappearance from the blood is estimated to be about one ounce an hour.

EFFECT ON BODY (pathology, pathophysiology)

The effect of alcohol on the central nervous system (the brain and spinal cord) is that of a depressant, decreasing its activity and thus reducing anxiety, tensions, and inhibitions. Taken in moderate amounts, alcohol gives a person a feeling of relaxation and well-being. However, if excessive amounts are ingested, poisoning or intoxication results with effects ranging from euphoria, loss of cognitive faculties & motor control, and unconsciousness. In addition to significantly altering mood and behavior, alcohol has various effects on the body. As a result of peripheral vasodilation (widening of small blood vessels) the face becomes flushed and the drinker will feel warm, although in fact a greater amount of body heat is lost. Small amounts of alcohol increase the flow of gastric juices and therefore stimulate the appetite and help digestion. However, large amounts of alcohol consumption over a long period of time can cause erosive gastritis (inflammation of the stomach lining with surface ulcers) and hematemesis (vomiting blood). The quantity of urine passed increases over and above that expected from the intake of drink because the production of ADH (antidiuretic hormones) is inhibited. Heavy drinkers often become dehydrated and a dry tongue and hangover are often the effects of the overconsumption of alcohol. Finally the effects of alcohol on sexual behavior are as summarized by William Shakespeare: " It provokes the desire but it takes away the performance."

Alcohol is a depressant, a drug that tends to slow down the working of the brain and other parts of the nervous system. It continues to affect the brain as long as it remains in the bloodstream. Once drinking stops, the effective concentration of alcohol in the blood is decreased slightly each time the blood passes through the liver, where alcohol is metabolized. The blood completes one cycle of circulation through the body about every three minutes. About 92 to 94 percent of alcohol ingested is metabolized and excreted; the remainder is excreted directly through breath and urine. Alcohol is broken down rapidly, and the rate of metabolism is influenced by the same factors that initially determined its rapid absorption and distribution through the body, i.e., by its water and lipid solubility and rapid interchangeability.

The bloodstream carries the alcohol molecule from the small intestine to the liver and then on to the rest of the body tissues including the central nervous system and the brain. In the first pass through the liver, harmful products that may have been absorbed from the small intestine into the bloodstream are detoxified. A significant amount of alcohol is removed from the bloodstream on the first passage of the alcohol molecule through the liver detoxification process. The liver removes toxic agents through the actions of a series of enzymes, alcohol dehydrogenase being the enzyme responsible for the breakdown of alcohol. Alcohol dehydrogenase exists in the human liver because a small amount of alcohol is generated in the gastrointestinal tract by fermentation processes of normal bacterial flora, so everyone has some free alcohol circulating in the bloodstream at all times, whether or not he or she drinks. If there was no system for the removal of this internally generated or endogenous alcohol, conceivably it could accumulate and produce many adverse effects.

When alcohol is metabolized in the liver, both enzymes and coenzymes are required. Coenzymes are involved in the transport of atoms from the alcohol molecule and make possible its conversion to a substance that can be subsequently broken down in a way similar to sugar. Coenzyme transport mechanisms transport products from one site to another, and during alcohol breakdown in the liver, these transport mechanisms are diverted from jobs they ordinarily perform. This diversion of coenzymes for alcohol metabolism results in a disruption of the physiological economy of the liver when large amounts of alcohol are consumed. One consequence is the impairment of other activities carried out by the liver, such as the detoxification of deleterious metabolic by-products and drugs. It is for this reason that the ingestion of large amounts of alcohol and other drugs is more dangerous than taking either alone.

Although alcohol dehydrogenase acts as the "master control" for the rate at which alcohol is eliminated, several other factors also influence the rate of alcohol degradation. One factor is the amount of stored sugar in the liver. If the drinker has been fasting, or has eaten poorly, the stores of sugar in the liver may be depleted, with a consequent slowing of the rate of alcohol metabolism. One practical consequence of this physiological fact is that many problem drinkers learn that they can prolong the duration of alcohol intoxication by not eating.

Since drinking alcohol on an empty stomach also facilitates rapid absorption, not eating produces a higher level of intoxication, which lasts longer. Although it is easy to slow down the breakdown of alcohol, there is no effective way to speed up alcohol metabolism once intoxication has occurred. The traditional notion that strong black coffee and a cold shower can speed sobriety is erroneous, since these do not alter the rate of alcohol metabolism. Although such maneuvers may stimulate the drinker, the amount of alcohol circulating in the body remains essentially unchanged and the drinker remains just as intoxicated.

The sensation of warmth after alcohol consumption reflects the increased blood flow to the skin. This sensation of increased warmth is actually associated with a loss of body heat. As peripheral blood vessels dilate, the expanded surface area releases more heat. Thus, although one may feel warmer after drinking, the actual heat loss may lower body temperature.

Paradoxically, alcohol acts to increase sexual desire but diminishes sexual performance in males. The same brain structures that regulate peripheral blood flow and control urine volume output also control the secretory patterns of hormones that influence sexual function. It has been discovered that alcohol directly affects these hormones and their regulatory interactions. One important sex hormone affected by alcohol is the male hormone, testosterone. Sufficient levels of testosterone are necessary for both sexual performance (penile erection) and for fertility. When testosterone levels are low, fructose production in the seminal vesicles is decreased and sperm motility is diminished, since the sperm cell uses fructose as a rapidly available energy source for movement of its flagella. Thus, heavy alcohol consumption may not only reduce sexual potency in males, but it may also act to decrease fertility.

Although men can achieve an erection when heavily intoxicated, they often fail to maintain the erection. Failure to maintain penile erection can lead to severely compromised sexual function. Studies of male alcoholics have shown that alcohol directly suppresses testosterone levels. Moreover, the magnitude of fall in testosterone levels is related to the amount of alcohol consumed. The more alcohol ingested and the higher the blood alcohol levels, the lower the testosterone levels. However, alcohol suppresses testosterone production in all men, not just alcoholics. Therefore, both alcoholic men and occasional social drinkers may suffer from impotence if they drink enough alcohol before attempting sexual intercourse.

Interestingly, men may experience increased sexual desire during heavy intoxication. This can be understood by considering the nature of the interaction between the brain and the testes. The brain regulates the pituitary gland, and the pituitary in turn regulates the testes. Testosterone production is preceded by a sequence of changes in hormone levels, and these hormones also may have some behavioral effects. The brain controls the production of a hormone (LHRH) that stimulates the pituitary gland to produce a second hormone (luteinizing hormone, or LH), which travels in the bloodstream to stimulate production of yet a third hormone, testosterone. Testosterone exerts a "feedback" effect on the brain and the pituitary. When testosterone levels are low, the brain and pituitary are signaled to produce more of the hormone that stimulates testosterone production. Consequently, when testosterone levels decrease following alcohol intake, the brain and pituitary are instructed to produce more hormones that stimulate the increased production of testosterone by the testes. Circulating levels of LH, the pituitary hormone that regulates testosterone production, are significantly increased when men are most intoxicated and when their testosterone levels are lowest. In addition to stimulating the testes to produce testosterone, the high circulating level of this pituitary hormone, LH, has a direct effect on behavior. Luteinizing hormone also stimulates brain cells that have a crucial role in the regulation of both sexual and aggressive behavior. When a surge of luteinizing hormone occurs after an alcohol-induced suppression of testosterone, it affects both the testes and the brain. Some scientists speculate that increased sexual desire following alcohol intake by males is related to the increase in luteinizing hormone secretion.

Therefore, it appears that when alcohol reduces testosterone levels, this signals the brain and the pituitary to produce more luteinizing hormone. The subsequent increase in luteinizing hormone levels stimulates more testosterone production and also stimulates increased sexual desire through its direct action on the brain. However, the brain and the pituitary are not the primary sites of alcohol's effects on male sex hormones; rather, alcohol suppresses testosterone production in the testes. Studies have shown that the testes metabolize and break down alcohol in a manner similar to that which occurs in the liver. Although the liver is the prime organ for metabolizing alcohol, the testes also possess the necessary enzymes to oxidize alcohol. Thus, when men drink alcohol, some of the alcohol is broken down by the testes. The enzymes used to metabolize alcohol in the testes are also crucial for the production of testosterone. When alcohol is metabolized in the testes, these enzymes are diverted from their normal role and testosterone production is decreased. It is the enzyme cofactor NAD that is depleted in the testes during alcohol oxidation.

In addition to decreasing testosterone and potency and increasing sexual desire, alcohol also has other effects on male sexuality. It has been found that male alcoholics can develop enlargement of the breasts (gynecomastia) and shrinkage of the testes (testicular atrophy), and liver disease associated with alcoholism is not necessary for feminization to occur in male alcoholics. It seems that prolonged suppression of testosterone levels is one important contributing factor.

Alcoholic women may also suffer severe derangements of reproductive function, and cessation of menstruation, or amenorrhea, is often reported. Some alcoholic women continue to menstruate, but more subtle disorders of the menstrual cycle may impair fertility. Anovulation and amenorrhea in alcohol abusers ensure infertility. Alcoholic women who do menstruate and ovulate may also be infertile because the luteal phase of the menstrual cycle is too short, or progesterone levels do not increase enough. When this happens, uterine development may be inadequate for the growth and development of the fertilized ovum, and a failure of ovum implantation or a spontaneous abortion may occur. Even if impregnation and implantation of the ovum does occur, the process of development is very fragile, especially during the first trimester. Moderate social drinking has been associated with spontaneous abortions during this vulnerable period. As with impotence and depressed testosterone levels in alcoholic men, these disorders are often reversible if women become abstinent after three or four years of alcohol abuse, in which menses may resume and normal pregnancies may occur. However, if alcoholism continues, irreversible structural changes in the reproductive system may occur and amenorrhea can persist for twenty years or more. The ovaries of alcoholic women on autopsy are often found to be smaller than normal, suggesting either atrophy or absence of structural components necessary for production of the ovum.

Since alcohol can affect sexual behavior and change hormone levels that are important in the regulation of male sexual function, this may have important implications for understanding how alcohol affects aggression. The brain centers that regulate sexual activity also are important in the regulation of aggressive behaviors. It is commonly believed that drinking enhances courage and alleviates fear and apprehension in the face of danger. Although alcohol may have a salutory effect in promoting courage and aggression in certain life-threatening situations, in most instances, alcohol-related aggression is destructive to the aggressor as well as to the victims. Alcohol-related aggression in this society exacts an enormous toll. Over 50 percent of highway fatalities are associated with alcohol abuse or alcoholism. Studies of alcohol's effects on driving behavior have consistently demonstrated that alcohol impairs skill and judgment. However, there is also increasing evidence that alcohol intoxication is associated with a great increase in risk-taking and overt aggression while driving. Police statistics indicate that intoxicated individuals, involved in minor accidents, frequently leave their vehicles and verbally or physically attack the other driver.

Another example of alcohol-induced aggression is the high incidence of homicide associated with alcohol abuse. Alcohol intoxication in the social drinker or sustained inebriation in an alcoholic is often accompanied by the enhanced probability of the emergence of aggression and belligerence. Alcohol may also produce profound dysphoria, depression, anxiety, and tension during intoxication, besides nausea and vomiting. The depression-facilitating effects of alcohol are accentuated at high doses. Alcoholic men who were somewhat depressed during sobriety became tearful and despondent during sustained drinking. Dreams and reveries about disturbing emotional events, repetitive expression of self-deprecation and guilt occurred more often during severe intoxication. It is as if alcohol gives access to memories and fears that are less available during sobriety.

ORGAN SYSTEMS MOST AFFECTED BY ALCOHOL

Alcohol abuse can lead to tissue damage and disease by any, or a combination, of three main mechanisms. First, alcohol or its breakdown products from metabolism can have a direct toxic or irritant effect on cells and tissues. Second, many alcoholics eat little or no nutritious foods -- alcohol satisfies their calorie requirements and at the same time reduces appetite through an irritant effect on the stomach. However, it provides no protein, vitamins, or minerals, so chronic alcoholics are prone to diseases caused by nutritional deficiency, particularly deficiency of vitamin B1 (thiamine). Third, a continuously high level of alcohol in the blood and tissues can cause wide-ranging disturbances in body chemistry. These disturbances can lead to hypoglycemia (reduced glucose in the blood) and hyperlipidemia (increased fat), the malfunction and disease of such organs as the heart, liver, kidneys, pancreas, stomach, and blood vessels. High alcohol consumption also increases the risks of cancer, nervous system disorders, heart and circulatory disorders and psychiatric illnesses.

The damage to the heart, liver, or other organs is perhaps the most common of the chronic effects of alcoholism. Prolonged heavy drinking can lead to severe and potentially lethal heart disease, hypertension, heart failure, and stroke. Relatively small amounts of alcohol (3 ounces) can induce a form of cardiac arrhythmia called ventricular tachycardia during an exercise test in people who have normal test results during sobriety. Since alcohol depresses cardiac contractility (or pumping ability) and changes conduction rates, these effects may contribute to the disturbances in cardiac rhythms. One specific form of heart disease linked with alcohol abuse is "Alcohol Cardiomyopathy." The heart muscle can be damaged by steady drinking of large quantities of alcohol as is characteristic of alcoholism. Such damage can result in severe abnormalities of the contractile ability of the heart, which may progress to serious heart failure. Not only the amount and frequency of alcohol consumption but many other lifestyle variables may also affect cardiac function. A sudden change in usual drinking and activity levels, strenuous exercise and heavy drinking over a weekend or on vacation have been associated with the so-called Holiday Heart Syndrome, characterized by irregular heart beats or dysrhythmias. These cardiac dysrhythmias may occur in individuals without clinical evidence of heart disease and can lead to fibrillation (abnormally rapid heart beat) and death.

Since the liver is responsible for oxidizing alcohol, continual heavy drinking can cause irreparable damage to the organ. Nearly all alcohol taken into the body passes through the liver, changing it into water and carbon dioxide. However, the liver can only oxidize one-half ounce of alcohol each hour. When forced to oxidize large amounts of alcohol, a condition known as cirrhosis, or scarring of the liver, results and can be deadly. Cirrhosis of the liver together with its complications, is one of the leading causes of death among adult males in the United States.

The amount of alcohol usually consumed by social drinkers can easily be broken down by the liver without any permanent ill effects. However, transient and reversible changes do occur in the liver when only moderate doses of alcohol are metabolized. Even cocktail party drinking sometimes results in an increased degree of fat concentration in the liver, a phenomenon described as "fatty metamorphosis." It is not known why fat tends to accumulate in the liver during the breakdown of alcohol, but this temporary change is not believed to have residual effects. There is also a change in the structure and composition of elements in the liver cell during alcohol metabolism, the most profound alcohol-induced changes occurring in the microscopic filamentous bodies in the liver cell known as the endoplasmic reticulum. This system becomes enlarged and swollen and disrupts normal cell function.

However, chronic alcohol abuse eventually leads to serious derangements of liver function, one form of which is called "alcoholic hepatitis." It is thought that a breakdown product of alcohol (acetaldehyde) has a toxic effect on liver cells and is the main cause of this diseases, although nutritional deficiency may also play some part. This form of hepatitis is similar in some ways to viral hepatitis but it usually has a more sudden onset. Patients with alcoholic hepatitis may become extremely ill within forty-eight to seventy-two hours following heavy drinking, and massive liver cell death may occur. Symptoms include high fever, severe abdominal pain, nausea, and vomiting. Fortunately, most attacks of alcoholic hepatitis are relatively mild and the patient survives. However, alcoholic hepatitis may prove fatal if blood pressure falls rapidly and the patient goes into shock.

If heavy drinking continues, hepatitis attacks may occur more frequently, and this condition may progress to the most serious form of liver disease, cirrhosis. Cirrhosis involves liver cell death with subsequent "scarring" of the liver. Such scarring or growth of fibrous tissue in the liver may occur after repeated episodes of alcoholic (or viral) hepatitis or it may develop insidiously with little or no warning. In many instances, alcohol abusers are not aware that they have cirrhosis of the liver until they develop jaundice or other signs of severely impaired liver function. Loss of appetite, abdominal pain, weakness and debility may increase in severity as cirrhosis progresses. With cirrhosis, continued alcohol abuse, especially in combination with a deficient diet, will eventually lead to death from liver failure. When this occurs, there is an accumulation of toxins such as ammonia (a by-product of normal nitrogen metabolism) that the liver is no longer able to detoxify. Patients may become confused, stuporous and eventually die in coma. Cirrhosis can also kill by exsanguination. When progressive scarring of the liver occurs many other abnormalities besides jaundice also develop. One of the most serious is the enlargement of veins which surround the esophagus. Severe enlargement of esophageal veins ("esophageal varices") may lead to spontaneous venous bleeding, which can be so severe and profuse that death occurs in a very short time.

Thus, high alcohol consumption can cause liver damage and diseases such as fatty liver, alcoholic hepatitis, cirrhosis, and liver cancer. They develop in sequence over a period of years. The risk of alcoholic hepatitis and cirrhosis developing increases in proportion to the amount of alcohol consumed and the number of years of high consumption; liver cancer develops in about one in five sufferers of cirrhosis. However, about one third of heavy drinkers never get liver disease and in another third, only a fatty liver develops.

Alcohol abuse also affects other organs such as kidneys, pancreas and stomach. Alcohol suppresses the effects of a hormone that controls urine output from the kidneys. This hormone (vasopressin) is secreted by the pituitary gland in the brain. Under ordinary conditions, vasopressin inhibits excessive urine output (diuresis). However, when alcohol suppresses the urine inhibitor vasopressin, this leads to a concomitant increase in urine output. Strangely, alcohol inhibits vasopressin only when blood alcohol levels are rising and not when blood levels are stable and falling. Thus, alcohol tricks the kidneys into making more urine, so the drinker urinates often. As a result, often dehydration, or a loss of needed body fluids, occurs. Prolonged heavy drinking can cause renal failure. The pancreas produces enzymes that are secreted into the intestinal tract to break down food products so that their nutrients can be absorbed. Pancreatitis is an inflammatory disorder of the pancreas, which may cause severe pain, debility, and even death. While the cause of pancreatitis is unknown, sustained consumption of large amounts of alcohol may increase individual vulnerability to this disorder. It is also recognized that once an individual develops pancreatitis, somehow drinking may cause a worsening of this condition.

Alcohol inhibits the absorption and transport of vitamins from the gastrointestinal tract and thus impairs nutrition. It also causes the stomach to make acids, possibly leading to an upset stomach. Drinking over a long period can cause gastric ulcers, or open sores, by the acids breaking down the lining of the stomach. Alcohol, taken in combination with other gastric irritants such as aspirin, may produce profound gastric irritation and severe bleeding.

Drinking alcohol over a long period of time destroys millions of brain cells, which cannot be repaired and replaced. The person who drinks enough alcohol to reach a state of unconsciousness will develop a substantial number of tiny brain hemorrhages, and at each of these points, brain cells will die from lack of oxygen. The damage is cumulative and irreversible. Alcohol can permanently damage the biochemical system responsible for conducting ions into and out of the nerve cell body. For example, alcohol can damage the structure of the outer membrane or wall of the nerve cell and impair the manufacture and transport of nucleic acids that are crucial for maintenance of the protein structures of nerve cells. Since certain types of nucleic acids have also been implicated in the process of memory storage, alcohol-related changes in memory function have been linked to adverse effects of alcohol on brain cell nucleic acids.

Transient memory dysfunctions may occur during alcohol intoxication. The spectrum of memory disorders associated with alcohol abuse range from brief episodes of forgetting to severe amnestic syndromes accompanied by structural changes in the brain. The fragmentary loss of recall for certain events during intoxication is sometimes called a dissociative effect of alcohol. Another common and more severe form of transient memory loss during drinking is called the "blackout." There is complete amnesia for events during a period of severe intoxication. The blackout can last for several hours or several days depending on the length of the drinking binge. However, it is temporary and usually does not include the period just before or after drinking began. Not only alcoholics suffer from blackouts when they are drinking heavily; normal, healthy social drinkers, and even people who usually abstain from alcohol, may have blackouts if they drink enough alcohol on a given occasion. The blackout seems to be related to the amount of alcohol consumed and the resultant blood alcohol level. The higher the alcohol dose, the greater the probability and severity of a blackout.

There are about 4,000 people in the nation who suffer from Wernicke-Korsakoff syndrome, a condition combining symptoms of palsy and neuritis. Long-term, heavy drinking causes a deficiency of B-vitamins (especially thiamin), which disturbs nerve functioning. The effect of this severe deficiency on the brain produces Wernicke's encephalopathy, with symptoms such as confusion, disturbances of speech and gait, and eventual coma. Korsakoff's psychosis may also occur. The effect on the peripheral nervous system (nerve pathways outside the brain and spinal cord) produces polyneuropathy, with symptoms such as pain, cramps, numbness, tingling, and weakness in the legs and hands. Severe thiamine deficiency in alcoholics can also cause heart failure (reduced pumping efficiency in the heart), usually combined with edema (fluid collection in the tissues). Alcoholics are more likely than others to suffer psychiatric illnesses ranging from anxiety and depression (frequently related to financial, work, or family problems) to paranoia. They are also more likely to have dementia (irreversible mental deterioration) develop. The incidence of suicide attempts and actual suicide is also higher among alcoholics.

New research also confirms earlier studies that showed increased incidence of some types of cancer in heavy drinkers. High alcohol consumption increases the risk of cancers of the mouth, tongue, pharynx (back of the throat), larynx (voice box), and esophagus, probably due to alcohol's irritant action. In each of these cancers, alcohol consumption along with smoking produces a much higher total risk of cancer than the sum of their separate risks. The alcohol and tobacco taken in act synergistically to release carcinogens trapped in the mouth, nose, throat, and lungs. Risk of cancer of the esophagus is 45 times greater among people who smoke and drink. And one study confirms that 76 percent of all oral cancer cases in men were caused by a combined use of tobacco and alcohol. Cancers of the liver, pancreas, large intestine, and rectum are more common in heavy drinkers. Heavy drinkers also have more peptic ulcers.

One effect of chronic drinking that is of special concern is that long-term alcohol abuse causes premature aging. Not only do people look older, but they can't think or remember as well as their nondrinking peers. Alcoholism also shortens the average life span by ten to fifteen years. The disease is progressive, which means that the alcoholic will always get worse if he or she continues to drink and continues to feel compelled to drink. Alcohol overdose is a common cause of death. Very large amounts of alcohol (such as a quart if drunk in five to thirty minutes) may occasionally cause death by anesthetizing the brain center that controls breathing. One thousand people die from alcohol overdoses each year.

SECONDARY EFFECTS OF ALCOHOL USE

Fetal Alcohol Syndrome: When a pregnant woman drinks alcohol, she may pass along to her unborn baby a condition called fetal alcohol syndrome (FAS). FAS is a serious health problem that tragically affects its victims and their families, but is completely preventable. Babies born with FAS tend to weigh less and be shorter than normal. They usually suffer from smaller heads, deformed facial features, abnormal joints and limbs, heart defects, poor coordination, problems with learning, and short memories. Causing FAS is child abuse that lasts for life. Therefore, pregnant women should be aware of the risks of high levels of alcohol consumption on a fetus, especially when combined with smoking, illicit drug use, malnutrition, or inadequate medical care. Children of alcoholic mothers were found to have delayed development of language, low I.Q. scores, abnormal hyperactivity, often accompanied by problems in school and difficulty in relationships with peers. Children whose mothers were alcohol abusers were only about 65 percent normal birth length and 38 percent normal weight. They also had distinctive abnormalities of the face and head, such as cleft lip and palate.

Other secondary effects may also include negative reactions from people consuming alcohol. For example, alcohol harms a person's ability to think and to make responsible decisions, which may lead to car accidents, violence, rape, fire, drowning, and death. Alcohol slows down reactions and interferes with judgment. About 40 percent of all traffic fatalities are alcohol-related. Alcoholics are 16 times more likely than others to die in falls, and 10 times more likely to become fire or burn victims. Alcohol is associated with over 50 percent of adult drownings. Up to 40 percent of industrial fatalities and 47 percent of industrial injuries are linked to alcohol consumption and alcoholism. It is estimated that 50 percent of all murders, serious assaults, sex-related crimes, robberies, and incidents of domestic violence are impacted by alcohol abuse. The National Institute of Alcohol Abuse and Alcoholism (NIAAA) calls alcoholism the nation's third largest health problem. The U.S. Department of Human and Human Services (DHSS) has called alcohol the most abused drug in the United States. The 1995 DHHS report on alcohol abuse depicted that as many as 100,000 deaths a year are related to alcohol.

Alcoholism has been called a family disease because when alcoholism hits one family member, the other members are affected as well. If the alcoholic has health or job problems because of drinking, the family must live with these problems. Most cases of spouse and child abuse involve people who have been drinking. One study found that 69 percent of child abuse and neglect cases were related to alcohol abuse. Wife- or husband-beating is also related to alcohol. While there is no evidence that alcohol actually causes a person to physically attack his or her family members, there is clear evidence that alcohol enables the alcoholic to act on his or her hostility. Beyond the issues of physical violence are many other problems that affect the family of the alcoholic. Financial insecurity, loss of a job, medical costs, excessive spending on alcohol, and general impractical attitudes toward money are common. Many families are ashamed of their problem and, for that reason, cut themselves off from society. Alcoholism isolates the alcoholic and his or her family from other people. Social lives are ruined for children and adults even if there is no physical abuse or violence in the home.

CLINICAL ASPECTS OF THIS SUBSTANCE

Alcohol has been used medicinally throughout recorded history; its medicinal properties are mentioned 191 times in the Old and New Testaments. It was primarily used as an antiseptic and a solvent. As early as the turn of the century there was evidence that moderate consumption of alcohol was associated with a decrease in the risk of heart attack. And now there is accumulating evidence that moderate alcohol users have a lower risk of heart attacks and coronary-artery disease than abstainers. However, the optimal amount of alcohol needed to reduce the risk for heart disease is unknown.

Moderate consumption of alcohol improves health and longevity in a number of ways. Alcohol improves blood lipid profile by increasing the HDL ("good") cholesterol and decreasing the LDL ("bad") cholesterol. It decreases thrombosis (blood clotting) by reducing platelet aggregation and fibrinogen (a blood clotter) and increases fibrinolysis (the process by which clots dissolve). It also reduces coronary artery spasm in response to stress, increases coronary blood flow, reduces blood pressure, reduces blood insulin level, and increases estrogen levels.

The moderate consumption of alcohol is also effective in reducing the incidence of a broad range of diseases and other health problems. A recent study published in the American Heart Association's journal found the abstainers' risk of stroke to be double that of moderate drinkers. The American Heart Association has also reported moderate consumption of alcohol to be associated with a dramatically decreased risk of stroke among both men and women, regardless of age or ethnicity. Harvard researchers recently found moderate drinkers to be almost 1/3 less likely to suffer Peripheral Artery Disease (a significant cause of death among the elderly) than those consuming less than one drink per week. A recent French study found moderate drinkers to have a 75% lower risk for Alzheimer's Disease and an 80% lower risk for senile dementia. A recent Harvard University study found the lowest levels of hypertension among young adults who consumed one to three drinks per day.