Alcohol Control Series - 4
“ALCOHOL CONTROL” SERIES, No. 4
Other titles in the “Alcohol Control” Series are: No.1. Burden and Socio-Economic Impact of Alcohol — The Bangalore Study Public Health Problems Caused by Harmful Use of Alcohol — Gaining Less or Losing More? Alcohol Control Policies in the South-East Asia Region — Selected Issues Reducing Harm from Use of Alcohol — Community Responses
No.2.
No.3.
No.5.
Front cover adapted from painting by: Manish Pathick, Class X, Universal Public School, New Delhi, India Back cover adapted from painting by: Priti Saini, Class XI, New State Academy, Sr. School, New Delhi, India
Contributors Dr Jitendra Nagpal Mrs Divya S. Prasad Dr Amulya Khurana Dr Swati Bhave Ms Shweta Khanna Mrs Nivedita Roy "Expressions" - The life-skills education and school mental health programme Child and Adolescent Centre
Vidyasagar Institute of Mental Health and Neurosciences New Delhi, India
Acknowledgement All Illustrations are courtesy of Alcohol and Drug Information Centre (ADIC) India. They have been reproduced with permission.
WHO Library Cataloguing-in-Publication Data World Health Organization, Regional Office for South-East Asia Alcohol Use and Abuse: What You Should Know (Alcohol Control Series No. 4)
Keywords 1. Alcoholism 2. Alcohol Drinking 3. Substance Abuse – in Adolescence – Prevention and Control 4. Alcohol-related Disorders ISBN 92 9022 275 1 (NLM classification: WM 270)
© World Health Organization 2006 Publications of the World Health Organization enjoy copyright protection in accordance with the provisions of Protocol 2 of the Universal Copyright Convention. For rights of reproduction or translation, in part or in toto, of publications issued by the WHO Regional Office for South-East Asia, application should be made to the Regional Office for South-East Asia, World Health House, Indraprastha Estate, New Delhi 110002, India. The designations employed and the presentation of material in this publication do not imply the expression of any opinion whatsoever on the part of the Secretariat of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The views expressed in documents by named authors are solely the responsibility of those authors.
Designed and Printed in India by: Macro Graphics Pvt. Ltd., www.macrographics.com For technical information, please contact: Dr Vijay Chandra, Regional Adviser, Mental Health and Substance Abuse Unit Dr Rajesh Pandav, Short-term Professional, Mental Health and Substance Abuse Unit Dr U Than Sein, Director, Department of Non-communicable Diseases and Mental Health Department of Non-communicable Diseases and Mental Health, World Health Organization Regional Office for South-East Asia New Delhi, India Email: mhs@searo.who.int
Frequently asked questions about alcohol use Q 1. What is alcohol? Alcohol is a generic term for many different chemical compounds; each with its own distinct properties. It is a clear, colourless liquid that comes from fermenting — or breaking down — natural substances such as fruit, corn, grain or sugarcane. The type of alcohol consumed by humans is ethyl alcohol or ethanol. Ethanol can have different colours, tastes, potency (strength) and flavours, depending on the fruits or vegetables used in its manufacture, the process of manufacture and the additives used. Beer, wine, liquor as well as medicines, colognes, cleaning solutions and even car fuel all contain ethanol.
Q 2. What are the different types of alcohol-containing beverages? Name of Beverage Brandy Whisky (Scotch) Rum Wine (Port, Sherry, Champagne, etc.) Beer Arrack Toddy Vodka Gin Breezer 4-8 50 - 60 5 - 10 35 - 60 40 - 50 3-5
Alcohol content (%) 40 - 55 40 - 55 40 - 55 10 - 22
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Q 3. I am confused about the various terms used when talking about alcohol. Please clarify what is alcohol use, harmful use of alcohol, alcohol abuse, and alcohol dependence? Alcohol use, as the term implies, is the consumption of alcohol. It does not indicate the amount used or the extent of harm from use. Alcohol use usually starts as a social phenomenon. Many communities consider the occasional use of alcohol, for recreational purposes or on social occasions, as ‘normal’ and ‘acceptable’. There is little awareness that even the occasional or social use of alcohol does carry a risk of road traffic injuries or industrial accidents. Intoxication from occasional use can lead to violence or socially inappropriate or embarrassing behaviour. Harmful use of alcohol is when some people, usually after a period of prolonged use, develop a pattern of use which causes damage to an individual’s health. Harmful use is not necessarily linked to drinking too much alcohol or drinking alcohol every day. Harmful drinking is usually related to the circumstances of drinking alcohol. Many patterns of consumption of alcohol can be considered as harmful use of alcohol, for example, drinking alcohol and driving — which can lead to road traffic injuries, “binge drinking” (drinking too much alcohol at one time) sometimes indulged in by teenagers, pay-day drinking when a person drinks heavily on the day he gets his salary, or pregnant women drinking alcohol. 2
Alcohol abuse, also called “problem drinking”, is a pattern of excessive drinking that results in adverse health and social consequences to the drinker, and often to those around the drinker. People with an alcohol abuse problem: ●
Use alcohol to help them change the way they feel about themselves and/or some aspects of their lives.
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Experience some problems associated with their alcohol use. Get complaints about their alcohol use. Lose interest in activities and hobbies that used to bring pleasure.
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Get irritable as their usual drinking time approaches, especially if alcohol isn't available.
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Keep alcohol in unlikely places at home, at work and in the car. Gulp drinks, become intoxicated intentionally. Drink alone or in secret.
Alcohol dependence refers to a cluster of symptoms. There are four main symptoms: ●
Craving — A strong need, or compulsion, to drink.
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Impaired control — The inability to limit one's drinking on any given occasion.
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Physical dependence — Withdrawal symptoms, such as nausea, sweating, 3
shakiness, and anxiety, when alcohol use is stopped after a period of heavy drinking. ●
Tolerance — The need for increasing amounts of alcohol in order to feel its effects.
The user knows that alcohol use causes significant impairment and though he/she may have a desire to cut down or control its use, does not or cannot give it up, resulting in heavier use of alcohol than intended and subsequent reduction of social or occupational activities. There are many factors, psychological, social, environmental, and genetic, that play a role in alcohol dependence. Alcohol dependence is not just bad behaviour or a habit. It is a chronic and progressive disease.
Q 4. Who is an “alcoholic”? A person is designated an “alcoholic” if he/she is alcohol-dependent.
Q 5. Do I have to drink alcohol to be socially accepted? No, you DO NOT HAVE to drink alcohol to be socially accepted. The need to feel accepted is strong during the teenage years. Self-identity is not yet formed; it is at a nascent stage, and this can lead to a lot of uncertainty and confusion. Teens want to belong to a group, and it is hard to belong if you are always going against what is considered “fashionable”. This is why teens are more likely than other groups to succumb to peer pressure. Most often this pressure is not very harmful. But in extreme cases the need to be accepted can lead people to do things that they would not normally do on their own. If a group norm includes alcohol use, the teen who joins the group may feel a great deal of pressure to start using alcohol. Why? Because the teen has found a place where he/she is accepted and does not want to lose the sense of security that acceptance in a group 4
entails. Friends are a big part of the emerging self-identity, and the thought of losing them during the early stages of identity development, is very hard to face. The irony is, that peer pressure to take drugs, or drink alcohol, or have sex, are often more a perception than reality.
Q 6. If my friends are having beer at a party, and they tease me because I am not drinking with them, then what should I do? When someone pressurizes you verbally, it can be difficult to resist. You will not want to risk making others feel bad, but it is important to stand up for yourself. Refuse politely but firmly. Explain to them that you will have an equally good time, enjoy being with them and you will participate in other activities, even without drinking alcohol. If it still becomes difficult for you, withdraw from such a group. Respect your decision and soon others will respect it too. Real friends will not push you to do something that you do not want to do. Instead, join a sports team, club, band or a voluntary organization. Being with people who share your interests will make it easier for you to have fun without alcohol.
Q 7. What is the harm in occasionally drinking alcohol socially? Social consumption of alcohol is an accepted part of the culture of some communities. But it is hard to know when the thin line between social use and harmful use is crossed. If you have wondered about what is the right amount of alcohol to drink socially, looking at drinking patterns is important. What is called “social drinking” changes, depending on fads and fashions. Generally, social drinkers use alcohol to relax and feel good, but they must be able to limit the amount consumed. Many people say they are social drinkers, and yet cannot imagine dinner or a good evening without alcohol. This is beyond just social drinking and the person has crossed the line to alcohol dependency. 5
It is often difficult for people to tell when they are crossing the line into dependency. Generally, a person is crossing the line if he/she: ● ●
Uses alcohol to help get through painful situations or feelings. Defends or hides his/her drinking; drinks alone, cannot remember what happened after drinking a little too much.
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Resents advice from other people, who want him/her to drink less. Cannot handle day-to-day matters because of alcohol. Develops signs of tolerance to alcohol.
Q 8. I drink beer, not alcohol. Is beer ok? Beer is also an alcoholic beverage, although it contains a lesser amount of alcohol than any hard liquor like whisky or rum. Beer contains 4 to 8 per cent alcohol. One 12-ounce can of beer is equal to one peg of whisky. So, if somebody drinks six cans of beer in an evening, he/she has consumed the equivalent of six pegs of whisky. Thus, depending on quantity, the effects of beer will be similar to any other type of alcohol.
Q 9. What happens when you mix drinks — do you get less drunk? Generally there are two ways people mix drinks — one way is to mix alcohol (could be rum, vodka, whisky etc.) with soda, colas or juice, and the other way is to drink different types of alcohol sequentially, one after the other (e.g. whisky after a bottle of beer). If you dilute alcohol with soda, cola or juice, you have 6
a larger volume of liquid to consume, which can be sipped over a longer period, thus giving the body more time to digest the alcohol and thereby slowing the immediate effects of alcohol. Drinking different types of alcohol sequentially is not any different as far as the alcohol load on the body is concerned. Thus, if someone drinks beer, rum and whisky sequentially, the effect will be the same as consuming the same quantity of any one type of alcohol (e.g. the same quantity of whisky or rum). It is actually the consumption of ethyl alcohol, the ingredient common to all alcoholic beverages that causes intoxication, not the mixing of drinks. Thus there is no biological basis to the saying: “Beer before liquor, never sicker; alcohol before beer, never fear”. Another important issue to keep in mind is to avoid mixing alcohol with other substances of abuse, e.g. with tobacco, pot or opioids. The effect of each is more or less independent. The concern here is that a person abusing more than one substance is likely to engage in greater high-risk behaviours and is more vulnerable to medical and social problems.
Q 10. Why are teenagers at a higher risk of developing alcohol use problems? Teenagers generally have less developed self-control and often behave impulsively. Alcohol use promotes thrill-seeking behaviour which can be dangerous and risky. The use of alcohol provides teenagers with an “excuse” to behave in an uncontrolled manner and to comply with dangerous group norms to gain acceptance and be a part of the “hep” group. Frequent use for thrill and pleasure-seeking can lead to chronic use and then to alcohol dependence. Teenagers are more sensitive to alcohol use because their bodies and brains are still developing. 7
Q 11. Is it true that women get more drunk than men? Yes. Women become more intoxicated than men after drinking the same amount of alcohol, even when the differences in body weight are taken into account. Alcohol easily mixes with body water and because a woman's body has proportionately less water than a man's, alcohol becomes more highly concentrated in a woman's body, leading to its enhanced effects on women.
Q 12. What makes teenagers begin drinking alcohol? Children see their parents and other adults who use alcohol socially. They also watch advertisements showing people enjoying life with alcohol. Thus alcohol seems harmless to many teens and a rather “fun thing to do”. Other issues which can lead teenagers to drink alcohol include: ●
Belief or hearsay that alcohol is “fun” and may even be “good for you”.
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Lack of knowledge about the adverse consequences (i.e. the dangers of alcohol use).
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Belief that it makes them happy, confident, less depressed and can make them feel important.
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To feel good, reduce stress and relax. Curiosity to experiment. Peer pressure. To escape from low academic performance. Their parents, siblings and friends use alcohol. They are easily influenced by advertising media. They have easy access to alcohol. 8
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Their society and culture permits alcohol consumption. There are family problems such as divorced/separated parents, absence of parents, parents who tolerate alcohol use.
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To fit in with a group and to feel older.
Q 13. What are the immediate effects of alcohol on me? ● ●
The first few drinks affect judgement and reaction time. More alcohol causes reactions to become even more sluggish and delays physical coordination.
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Far too much alcohol can suppress some body functions and, in extreme cases result in death.
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Often alcohol consumption is associated with several high-risk behaviours such as rash driving, getting into fights, unsafe sexual behaviour, drowning, and other fatal accidents.
One to three units Four to six units Seven to nine units Ten to fifteen units Twenty units plus
Thirty units plus Reproduced with permission. 'A Lot of Bottle', 1998, Derek Rutherford. Publisher, Institute of Alcohol Studies, Alliance House 12 Caxton St., London SWIH OQS
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Q 14. How can alcohol use harm me medically? Alcohol use has been linked to numerous serious harmful effects on the body. Some medical complications occur soon after use, some become apparent after a few months/few years and some after many years of chronic use. Many of these effects can be fatal. A few adverse effects are summarized in the table below:
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Slurred speech Slower reaction time Impaired thinking and judgement Gastric problems Possible unconsciousness, coma and death Headache Insomnia Hangover Loss of memory Severe brain damage leading to dementia and Wernicke-Korsakoff syndrome Cirrhosis of liver Liver cancer Foetal alcohol syndrome Menstrual irregularities Impotence Peptic gastric ulcers
Acute / Immediate complications
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Intermediate complications
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Long-term complications
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Q 15. How can alcohol use affect day-to-day functioning? School ● ●
Family ●
Social ●
Legal ● ● ●
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Inefficiency Poor performance Frequent absence Accidents in school Suspension from school
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Frequent fights Neglect of family duties Physical violence with family members Long absence and running away Rejection
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Distance from friends Misbehaviour with others Decreased social reputation Loss of position Social isolation Constant borrowing Inability to return borrowed money Fights, quarrels, theft
Disobeying rules Drunken driving Thefts and petty crimes Involvement with criminal gangs Arrests and court cases Conviction Imprisonment
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Q 16. Is it safe to drink alcohol during pregnancy? No. Drinking alcohol during pregnancy can have numerous harmful effects on the unborn child, ranging from mental retardation, organ abnormalities to learning and behavioural problems. Moreover, many of these disorders in newborns last into adulthood. While it is not known exactly how much alcohol has to be consumed by the mother to cause this damage, but the link between alcohol consumption by a pregnant woman and damage to the unborn child has been definitely established. Therefore, for women who are pregnant or are trying to become pregnant, the safest course is to abstain from alcohol.
Q 17. Is it true that if you are taking some medication, then you should not drink alcohol? Yes. More than 100 medications interact with alcohol, leading to increased risk of illness, and, in some cases, death. The effects of alcohol are increased with certain medicines, such as sleeping pills, common cold medications (anti-histamines), anti-anxiety drugs, and some pain killers. 11
In addition, the effect of certain critical medicines, such as diabetes and heart medicines, can be neutralized by alcohol, leading to serious adverse effects in the patient.
Q18. If my father is an alcoholic will I also become one? You may be at a higher risk, but not definitely destined to be one. Alcoholism tends to run in families and genetic factors partially explain this pattern. Research studies show that children of alcoholic parents are about 4 times more likely to develop alcoholrelated problems. However, a child of an alcoholic parent will not inevitably develop alcoholism, just as a person, with no family history of alcoholism, can become alcoholdependent. A person's environment, such as the influence of friends, stress levels, and the ease of obtaining alcohol, also may influence drinking and the development of alcoholism. Still other factors, such as social support, may help to protect even high-risk people from alcohol-related problems.
Q 19. How can I know whether I or someone close to me has an alcohol problem? Four simple questions, which comprise the CAGE test developed by Dr John Ewing is widely used for alcohol abuse screening. (To help remember these questions, note the first letter of a key word in each question spells “CAGE”). 12
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Do you feel that you should Cut down on your drinking? Do you feel Annoyed when other people comment about your drinking habits?
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Do you ever feel bad or Guilty about your drinking? Do you ever need a drink (Eye opener) first thing in the morning to steady your nerves or to get rid of a hangover?
A “yes” to any one of these question suggests possible alcohol-related problems. More than one “yes” answer means it is highly likely that the person is abusing alcohol. If you think that you or someone you know might have an alcohol-related problem, it is important to talk to the family of the person and persuade him/her to see a doctor or another health-care provider right away. The doctor can determine whether a drinking problem exists and, if so, suggest the best course of action.
Q 20. Is it true that once an alcoholic, always an alcoholic? Can alcoholism be cured? Many alcoholics have tried to stop drinking. Some develop withdrawal symptoms due to the physical and psychological dependence of the body on alcohol. This bad experience may force a person to continue drinking alcohol. However, most patients are able to withdraw from alcohol without medication, but patients with moderate-to-severe symptoms are best treated under supervision and need medication to suppress symptoms. This process is called detoxification. 13
Despite detoxification, research studies show that only a minority of alcoholics remains sober for a year after treatment, while others have periods of sobriety alternating with relapses. Still others are unable to stop drinking for any length of time. The longer one abstains from alcohol, the more likely it is for one to remain sober. It is important to remember that many people relapse once or several times before achieving long-term sobriety. If a relapse occurs, it is important to try to stop drinking once again, and to get whatever help is needed to abstain from alcohol. Relapses are common and do not mean that a person has failed or cannot eventually recover from alcohol dependence. More important than detoxification is rehabilitation of the patient. There are promising types of counselling that teach recovering alcoholics to identify situations and feelings that trigger the urge to drink, and to find new methods of coping that do not include the use of alcohol. These treatments may be provided in a hospital or residential treatment setting or on an outpatient basis. In addition, the recovering alcoholic requires the strong social support of his/her family and friends.
Q 21. How long does it take for an alcohol-dependent person to get completely cured? There are various phases of treatment. In the initial phase the person is motivated to stop consuming alcohol. The second phase of detoxification takes about 2 to 3 weeks and involves helping the patient to safely withdraw from alcohol. For the next 3 to 12 months or more, a combination of long-term medicine-based treatment, individual psychotherapy, family intervention, group therapies and rehabilitation is followed. In the after-care phase the focus is on maintaining longterm abstinence and recognition and prevention of relapse. This may 14
continue for 3 to 5 years or even longer. This comprehensive and prolonged management is required if the person is to recover completely.
Q 22. Can a problem drinker simply cut down? It depends. If a person has been diagnosed as alcohol-dependent, the answer is “no.” Alcohol-dependent persons who try to cut down on drinking rarely succeed. Completely stopping alcohol, that is abstaining, is usually the best course for recovery. People who are not alcohol-dependent but who have experienced alcohol-related problems might be able to limit the amount they drink. If they cannot stay within those limits, they need to stop drinking altogether.
Q 23. Is it important to tell my friend's family of his/her alcohol use? Although it may appear that, by informing his/her family, you are breaking the trust that your friend has in you, and you are also worried that his/her parents may get very angry with him/her, still it is important to involve his/ her family because: ● ●
The family can establish contact with some treatment agencies. They can discuss with the doctor and understand the nature of alcohol-related problems and steps for treatment.
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They can provide constant supervision and monitoring of the patient. They can help the patient in managing the other social, financial and psychological problems.
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They can help him/her in treatment if relapse occurs. They can provide the necessary social support to the patient. 15
Q 24. What can I do to prevent/safeguard myself from being pressurized to drink alcohol? You can prevent /safeguard yourself from being pressurized to drink alcohol by giving the following justifications: ● ● ● ● ● ● ● ● ● ● ●
“I don't like the taste.” “I don't like the way it makes me feel.” “I want to stay in control.” “I'll have more fun by being sober.” “I know alcohol may cause problems later.” “Drunk driving kills thousands of people every year.” “Drinking goes against my beliefs.” “I don't want to risk my health.” “Hangovers are no fun.” “I know that it's illegal for people under 18.” “I just don't want to.”
Being clear about your reasons will help you follow through on your decision. Steer clear of parties or places where you know people will be drinking. If you do go, think about how you will deal with alcohol. Drink soda, mineral water, or fruit juice instead of alcohol. Do not attend a party unprepared to resist alcohol.
Q 25. Has research identified any risk factors which predispose adolescents to alcohol dependence? Yes. Researchers have identified certain factors which promote an occasional user of alcohol to become a chronic user, thus leading to alcohol dependence. The following are predisposing factors: ●
Parental and sibling alcohol use. 16
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Poor problem solving skills. Excessive peer pressure. Inadequate supervision of adolescents. Poor parent/child relationships. Excessive family conflict, marital discord, and domestic violence. Family chaos and stress. Poor parental mental health. Family's social isolation.
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Some myths and misconceptions about alcohol consumption Myth Alcohol enhances sexual performance and desire.
Fact Shakespeare's quote that alcohol “provokes the desire but inhibits the performance” is well known. Alcohol interferes with achieving erections. In research studies of certain cases, alcohol has been shown to reduce sexual desire. But how one behaves after drinking alcohol, depends on how one wants to behave or how the alcohol-consuming group is behaving.
Myth Alcohol helps people to forget their problems.
Fact This has become a 'truth' because regular and heavy alcohol-users often say this is the reason why they drink alcohol. Very often the opposite is found to be true – people bring up forgotten problems only when they are intoxicated.
Myth Alcohol is a stress buster.
Fact Alcohol is frequently resorted to as a “cover up” during times of temporary or ongoing stress or grief experienced due to the loss of a loved one or the end of a relationship, unresolved family tensions or chronic work stress. However, alcohol increases the level of biological stress that is placed on the body. Adrenaline levels increase in the body as we drink. We may feel more relaxed when we drink alcohol, but the body actually comes under additional stress. 18
Myth A man needs to drink alcohol to prove his manliness.
Fact On the contrary, people who need to use alcohol develop a tolerance for it and become dependent on it, thereby losing their will power and independence.
Myth One needs to drink alcohol to be trendy and part of the group.
Fact Behavioural research has documented that in a group drinking alcohol; even those who are not drinking can have an equally good time and behave in the same uninhibited manner. Adolescents call this “getting high on other people’s alcohol”. Forcing or urging someone to drink as a condition of group membership or acceptance can lead to tragic consequences, hospitalization, sexual and other types of violence and even death. Ultimately, alcoholics can be very lonely people shunned by family, friends and society.
References Desai NG, Nawamongkolwattana B, Ranaweera S, Shrestha DM, Sobhan MA. Prevention of harm from alcohol use: get high on life without alcohol. New Delhi: World Health Organization, Regional Office for South-East Asia. Document SEA/Ment/122, 2003. World Health Organization, Regional Office for South-East Asia. Facts on alcohol use and abuse. New Delhi, 2003. National Institute on Alcohol Abuse and Alcoholism. FAQs for the general public English. Bethesda. (www.niaaa.nih.gov/FAQs/General-English, accessed 15 June 2006). Addiction Recovery Agency. Frequently asked questions about alcohol. (http://www.addictionrecovery.org.uk/ACAD-BAS-FAQPage.html, accessed 15 June 2006). Obot IS, Saxena S. eds. Substance use among young people in urban environments. Geneva: World Health Organization, 2005. 19
Reproduced from the painting by : Rummana Zaidi, Class X, Holy Child Sr. Sec. School, Tagore Garden, New Delhi, India
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