Alcohol Craving, Abuse and Dependence and Alcoholism

Alcohol Craving

Alcohol craving is a desire to experience the previously experienced effects of alcohol. Craving for alcohol is usually strongest in the first 6 months after stopping drinking, but may, in some individuals, persist for years thereafter ^[1,2]. Alcohol craving may have different underlying mechanisms ^[1]:

• Relief craving. Some people, women more likely than men, crave for alcohol to find relief from anxiety, depression or withdrawal symptoms ^[1,3].
• Reward craving. Individuals with reward seeking drink when they are in a pleasant mood ^[4].
• Obsessive craving means having obsessive thoughts about drinking alcohol.
• Compulsive craving is associated with compulsive behavior toward drinking. High insulin levels were associated with compulsive alcohol craving ^[5,6].

The type of craving in an individual undergoing alcohol treatment is evaluated with the help of a questionnaire called the Obsessive Compulsive Drinking Scale (OCDS).

Certain substances and alcohol craving:

• Severe nicotine dependence is associated with higher alcohol craving ^[7].
• Nutritional deficiencies in chronic drinkers may contribute to alcohol craving ^[8].
• On the biochemical level, alcohol craving may be associated with increased levels of the hormones leptin ^[10], ghrelin ^[9], insulin ^[6], thyroid hormone triiodothyronine (T3) ^[6] and aldosterone ^[6], and decreased levels of the hormone adipocentin ^[6] and endogenous opioid beta-endorphin ^[14,15].
• According to one large 2009 study, hypoglycemia or hyperglycemia by themselves are not associated with alcohol craving ^[16].

How can you reduce alcohol craving?

• Set the goals to your work and relationships and follow them.
• Chose a diet you believe is appropriate for you. Both alcohol and carbohydrates increase serotonin levels ^[18]. When you stop drinking, your serotonin levels may drop, so you may start to crave for sugar. The same way, when you reduce carbohydrates in your diet, you may start to crave for alcohol, so.try to eat enough complex carbohydrates (such as whole-grain bread) to reduce alcohol craving.
• Find out appropriate sleeping pattern and stick with it.
• Be physically active: it does not necessary be jogging, it can be walking and doing your regular work.
• Avoid places and people that trigger your desire for drink.
• When you are in a temptation to drink, relive the feelings of peace and joy and remind yourself of good things that happened to you after stopping drinking.
• You can practice “urge surfing,” a method in which you accept the feeling of craving when it appears, sit down comfortably and observe closely what is happening with your body, thoughts and emotions. This way you can “ride out” the craving in few minutes, which is usually much faster than when you try to ignore it or fight with it.
• Reference: ^[17]

Medications and Remedies to Reduce Alcohol Craving

Naltrexone, acamprosate ^[19], haloperidol, olanzepine and a combination of tiapride and carbamazepine have been shown to be effective in reducing alcohol craving in some studies ^[20].

Kudzu root extract may reduce alcohol craving; it inhibits ALDH2, so it works much like disulfiram (see below) ^[11,12,13].

There is INSUFFICIENT EVIDENCE about the effectiveness of the following herbs and medications in reducing alcohol craving:

• Herbs: St. John wort (Hypericum perforatum) leaves, danshen (Salvia miltiorrhiza) root extract, Tabernathe iboga root extract (containing ibogaine), ginseng (Panax ginseng) root extract, evening primrose (Oenothera biennis) oil, milk thistle (Silybum marianum) fruits, or scullap (Scutellaria laterifolia) ^[21,22].
• Medications: serotonin agonists, such as buspirone, ondansetron and ritanserin ^[23,24], SSRIs: fluoxetine and sertraline ^[24,25]; lithium ^[25], baclofen ^[26,27], niacin, L-glutamine, gabapentin ^[28], gamma-hydroxybutyric acid (GHB) ^[29], pregabalin ^[30] and varenicline ^[31].
• SAAVE is a combination of vitamins and amino acids, which are precursors of neurotransmitters serotonin, GABA, enkephalins and catecholamins that are supposedly deficient in alcoholics ^[32]. In a couple of studies, SAAVE was associated with reduction of withdrawal symptoms and increased persisting in treatment programs ^[33].
• Synaptamine is a nutritional complex that was associated with decreased craving in alcohol treatment, according to few studies ^[33].

Alcohol Abuse

You abuse alcohol when you continue to drink excessively despite developing problems with health, work, relationships or law. Alcohol abuse is not already alcohol dependence.

Alcoholism or Alcohol Dependence or Addiction

You may be alcohol dependent if you answer positively to at least two questions from the CAGE questionnaire ^[34]:

1. Have you ever felt you should Cut down on your drinking?
2. Have you ever felt Annoyed at others’ criticisms of your drinking?
3. Have you ever felt Guilty from anything after drinking?
4. Have you ever had an “Eye-opener”—a drink in the morning?

Alcoholism or alcohol dependence or addiction is a chronic disease in which you ^[35]:

• Drink excessively on a regular basis
• Drink in the morning to prevent or relieve withdrawal symptoms
• Often drink alone
• Are unable to limit your drinking
• Feel a strong craving for alcohol
• Develop tolerance to alcohol – you need increasing amounts of alcohol to feel the same effect
• Experience withdrawal symptoms, such as nausea and shaking, when you stop drinking
• Experience frequent blackouts – loss of memory for the events that occurred during drinking
• Spend a lot of time for alcohol-related activities
• Have alcohol-related problems with school, work, relationships, health or law

Psychological dependence to alcohol is a perceived uncontrollable need for the alcohol to feel good or to keep from feeling bad.

Physical dependence to alcohol is an uncontrollable need to drink alcohol that is generated by biochemical changes in the brain that develop after the long-term drinking ^[36]. The  physically addicted person has developed alcohol tolerance and usually has withdrawal symptoms after stopping drinking, so he or she likely drinks in the morning in order to prevent them ^[36].

If you think you have a drinking problem, speak with your doctor or someone you can trust.

Types of Alcohol Dependence According to Lesch

• Type 1 alcoholics drink to relieve withdrawal symptoms. They often have heavy withdrawal symptoms with seizures. They often have increased levels of homocysteine, glutamic acid and leptin. They may achieve better treatment results with acamprosate.
• Type 2 alcoholics drink to relieve anxiety. They are often nicotine-dependent and have increased levels of the hormone prolactin, which is also increased in stress, and leptin. They may achieve better treatment results with acamprosate.
• Type 3 alcoholics drink to relieve depression. They may achieve better treatment results with naltrexone.
• Type 4 alcoholics drink to adapt to brain defects, behavioral disorders, and a high social burden. They often have increased levels of glutamic acid. This type is often associated with left-handedness and nicotine dependence. They may achieve better treatment results with naltrexone.
• Reference: ^[37]

Early-Onset Alcohol Use

Individuals who start to drink before the age of 15 are at several times greater risk to develop alcohol dependence later in life than those who start to drink after 21 ^[38].

Individuals who became alcohol dependent early in their lives often have Attention Deficit Hyperactivity Disorder (ADHD) ^[39].

Risk Factors for Alcoholism

• Availability of alcohol
• Inability to solve personal or psychological problems, such as anxiety, panic attacks, depression, attention deficit hyperactivity disorder (ADHD), traumatic life experiences (post traumatic stress disorder or PTSD), or psychiatric illness, such as bipolar disorder or schizophrenia
• Pain caused by chronic diseases, such as cancer or arthritis ^[40]
• Alcoholism in the family, friends or coworkers who drink excessively
• Nicotine dependence ^[41,42]
• Genetic predisposition ^[53]

Up to 50% of East Asians have a deficiency of the enzyme ALDH2, what results in the accumulation of acetaldehyde in their tissues after drinking alcohol, what make them sick; this results in much less alcoholism in East Asia than in other parts of the world ^[54].

Some studies have shown that reward deficiency syndrome (RDS), which may include excessive drinking, smoking, illegal drug abuse, compulsive eating, attention deficit hyperactivity disorder (ADHD), Tourette syndrome, inappropriate sexual behavior, pathological gambling or uncontrolled anger, is caused by a genetic dysfunction of the dopamine D2 receptors ^[43]. Dopamine release in the brain is responsible for the pleasant feelings, such as peace and reward. Chronic abuse of alcohol leads to inactivation of the brain reward cascade, reduction of dopamine receptors and dopamine release what can cause unpleasant feelings, such as anxiety, anger and low self-esteem ^[33].

Treatment of Alcohol Dependence

1. The first step of treatment of alcohol dependence is detoxification or “drying out,” which may last for 4-10 days. It usually takes place in the hospital or detoxification center and includes management of acute withdrawal syndrome (IL) after stopping drinking. Treatment may include intravenous fluids, dietary supplements, such as thiamin, folate, magnesium, potassium, zinc, glucose, sedatives, benzodiazepines (diazepam, lorazepam), antipsychotics (in hallucinations) or other drugs as prescribed ^[45,46,47].

Gradual withdrawal by decreasing amounts of alcohol is NOT recommended ^[48].

2. The next step of alcoholism recovery is physical rehabilitation that may require staying in the hospital for several weeks to two months. During this time, a doctor may prescribe certain drugs ^[52]:

Naltrexone is a FDA approved drug for reducing alcohol craving. It blocks opioid receptors in the brain and thus eliminates rewarding effects of alcohol mediated through these receptors. Drinking alcohol after taking naltrexone does not cause sickness ^[19]. A related drug vivitrol as an intravenous injection once per month is available. Naltrexone should not be used in opiate-dependent individuals and within 72 hours before a scheduled surgery ^[55]. Side effects may include insomnia, nausea, anxiety, headache, muscle aches, rash, dizziness, fatigue and chills, liver damage and increased suicide risk ^[55].

Acamprosate is a FDA approved drug that may reduce alcohol craving. It does not cause sickness when taken along with alcohol. Acamprosate may be prescribed to persons with protracted alcohol withdrawal syndrome. Acamprosate is not effective in individuals who continue to drink and is not intended to prevent acute withdrawal symptoms ^[19,49]. Acamprosate was effective in treating alcohol dependence in some studies ^[50], but not in others ^[20]. Side effects may include diarrhea, itchiness, dizziness, muscle weakness, headache, nausea, anxiety and insomnia, depression and increased suicide risk.

Disulfiram is a FDA approved drug to treat alcohol dependence. It inhibits the enzyme ALDH2, which normally breaks down acetaldehyde to acetate, what results in the accumulation of acetaldehyde in the tissues and thus causes “disulfiram reaction” within 15 minutes of ingestion alcohol; symptoms may include nausea, vomiting, throbbing headache, facial flushing, sweating, difficulty breathing, rapid heart rate, confusion and seizures ^[51]. Disulfiram itself (without combination with alcohol) may have side effects: drowsiness, headache, metallic or garlic taste in mouth, blurred vision, dark urine, yellowing of the skin and eyes, weakness, seizures, numbness in the arms and legs, weakness or severe allergic reactions with hives, difficulty breathing, swelling of the mouth, face, lips or tongue ^[51].

• Dopamine antagonists haloperidol and olanzepine were effective in reducing alcohol craving and consumption in respective studies ^[24].
• A combination of tiapride and carbamazepine was shown to be effective and safe in treating alcohol dependence in 2 studies ^[56,57].
• Here is a short review of other medications to treat alcohol dependence.
• Dietary supplements, such as vitamin B complex, vitamin C, folate, potassium and zinc, may be necessary for some weeks or months.

3. The third step is personality recovery, which may last from few months to several years. During recovery from alcoholism:

• Inform people around you that you do not drink
• You might need to stay away from your previous drinking pals
• Have regular sleep and diet
• Find a regular job
• Set a goal in your life
• You may join one of the local alcohol recovery support groups.

Alcohol Recovery Support Groups

Examples of alcohol recovery support groups:

• Al Anon (support for the alcoholic’s family and friends)
• Alateen (for teens)
• Alcoholics Anonymus (AA)
• Dual Recovery Anonymus (DRA) (for addicts with mental health problems)
• Secular Organizations for Sobriety (SOS)
• Self Management and Recovery Training (SMART)
• Women for Sobriety (WFS)