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Alcohol

Contents

Also known as

booze, bevvy, ethyl alcohol, ethanol, grog, piss, liquor, charge, nip, brew, hooch, juice, sauce

Classification

Depressant, sedative

Overview

Skull.jpg Death may occur when alcohol is combined with depressants such as opiates, benzodiazepines, barbiturates, thienodiazepines or other GABAergic substances.

Alcohol is a psychoactive drug consumed in thousands of varieties of alcoholic drink [1].

What we mean by alcohol here is alcoholic drinks, such as beer, wine and spirits. The scientific name for the alcohol in these drinks is ethanol or ethyl alcohol. Other chemical forms of alcohol, such as methanol and butanol, are much more toxic than ethanol and should not be consumed by humans. When FRANK talks about alcohol it is referring to ethanol [2].

Alcoholic drinks vary in strength. Beers contain about 5% alcohol, spirits like vodka usually contain about 35%. Wine is in between. Bottles and cans of alcohol should have information on how much alcohol they contain as a percentage [1].

Alcohol is a nervous system depressant, meaning it works by slowing down parts of the brain. Areas that it affects include those that control inhibition, thought, perception, attention, judgement, memory, sleep and coordination [1]. Just enough can make you feel sociable; too much and you'll have a hangover the next day, and may not even remember what you got up to; and way too much alcohol in a single session could put you in a coma or even kill you.

Although it's legal for people aged 18 and over to buy and drink alcohol, that doesn't mean it's safe [2].

The effects of alcohol can include -

  • Reduced feelings of anxiety and inhibitions, which can help you feel more sociable.
  • An exaggeration of whatever mood you're in when you start drinking.
  • A wide range of physical health problems, either as a result of binge drinking or from more regular drinking. The problems caused by alcohol include high blood pressure, stroke, liver disease, cancers and falls and other accidents [2].

Alcohol is the popular name for 'ethanol', which is a colourless chemical.

It is produced by the process of fermentation, in which yeast acts to convert the sugars contained in fruits and vegetables into ethanol. The resulting liquids, together with their added flavourings, form what are collectively known as alcohol. There are three main forms of alcoholic drink: beers, wines and spirits [3].

What does it look like?

Alcohol is a liquid [4].

Source

Ethanol in its pure form is a volatile, flammable, colourless liquid. Ethanol can be produced from ethylene and used in the petrochemical industry, and it can be made by fermenting sugars with yeast for use in the alcoholic beverage industry. Alcoholic drinks are produced in distilleries and breweries throughout Britain and the world. Alcoholic drinks can be broadly split into two groups - fermented and distilled. Fermented drinks include beers, wines and ciders; distilled beverages (spirits) are made by distilling fermented beverages and include whiskeys, brandies, rum, vodka and gin. Alcoholic drinks vary in strength (depending how much ethanol is added), they vary depending on what starting material has been used (grains, fruits etc), and also by what additional ingredients are added such as herbs or spices. It is estimated that there are over 170,000 licensed outlets such as public houses, bars, and shops in the UK alone [5].

Prevalence

Alcohol is our favourite drug. According to NHS statistics released in June 2016 -

  • 28.9 million people in Great Britain report drinking alcohol in the previous week. This equates to 58% of the population.
  • In 2014, 38% of secondary school pupils had ever drunk alcohol, the lowest proportion since the survey began when it was 62%.
  • In 2014/15 there were 1.1 million estimated admissions to hospital where an alcohol-related disease, injury or condition was the primary reason for admission or a secondary diagnosis. This is 3% more than 2013/14.
  • Men accounted for nearly two-thirds of the admissions.
  • In 2014, there were 6,831 deaths which were related to the consumption of alcohol. This is an increase of 4% on 2013 and an increase of 13% on 2004.
  • There is some evidence that drinking is declining amongst young people but increasing amongst baby boomers [6].

Statistics for England published by NHS Digital in December 2016 revealed -

  • 31% of men and 16% of women drank over 14 units in a usual week.
  • Regular drinking by children was rare. 1% of both boys and girls aged 8 to 15 reported usually drinking once a week or more. The proportion who reported drinking once a week or more increased from fewer than 1% of both boys and girls aged 8, to 5% of boys and 4 per cent of girls aged 15 [6].

Street price

Alcoholic drinks range in price from under £1 for cheap lagers through to many thousands for expensive wine [7].

Why take it?

Sought after effects

  • relaxed feeling,
  • enables people to enjoy socialising,
  • release pent-up aggression [3].
  • mild intoxication,
  • cheerfulness,
  • relaxation [5].

Undesired effects

  • weakens bodily control and coordination,
  • blurred vision,
  • slurred speech,
  • decreased sexual performance [3].
  • dehydration,
  • disinhibition,
  • confusion [5].

Causes

There are numerous factors that may interplay to form alcoholism in one individual while another may be able to curb their drinking. Alcoholism is thought to be caused by a number of factors that work together [8]. These may include -

Genetic

Individuals who have a relative, especially a first-degree relative such as a parent or sibling, with alcoholism are more apt to grow up to develop problems with alcohol or other substance addictions [8].

Biological

When individuals drink steadily over a prolonged period of time, they may develop a physical dependence upon alcohol; meaning that their body has become dependent upon the substance to function [8].

Environmental

Individuals who grow up in a home that is ruled by addiction are more likely to grow up to develop a problem with addiction. In addition, individuals who begin to abuse drugs and alcohol at younger ages are at higher risk for developing addiction later in life [8].

Psychological

Individuals who struggle with underdiagnosed or untreated mental health issues are more likely than others to develop a problem with substance abuse and addiction, including alcoholism. Many individuals report beginning to drink as a means to overcome low self-esteem and self-image as drinking bolsters their feelings about themselves [8].

Brain Structures

Certain structures that associated with controlling craving for alcohol and other substances have been found to be smaller in individuals with alcohol use disorders compared with others [9].

Brain Chemistry

There is some research that suggests that individuals with alcohol related problems have high levels of circulating serotonin in the brain, a chemical responsible for neural communication, is related to lower levels of tolerance to alcohol. This means that these individuals have a shorter time until they develop the need to increase the amount of alcohol they drink to achieve the desired effect [9].

Temperament

Individuals with alcohol use disorders have been shown to be more likely to display a lack of inhibition, believed to be an inherited temperamental quality, than others. It has been suggested that this quality causes individuals to lack the physiological warning system that suggests when they've had enough to drink and to stop [9].

Life Stressors

One effect of alcohol is that it has a numbing effect on emotions. Some people experience a huge number of life stressors which they are unable to control or just become so overwhelmed by negative emotions they stop trying to do anything. Alcohol may be used in this type of situation to numb the negative emotions they feel are crushing them [9].

What are the different forms of alcohol?

When a person drinks an alcoholic beverage, it is very unlikely that he or she is actually drinking pure alcohol; pure alcohol is extremely potent and takes only a few ounces to raise a person's blood alcohol level into the danger zone [10]. The ethanol concentration for common types of alcoholic drinks is as follows -

  • beer - 4% - 6%,
  • malt liquor - 5% - 8%,
  • wine - 7% - 15%,
  • wine coolers - 5% - 10%,
  • champagne - 8% - 14%,
  • spirits (vodka, rum, whiskey, etc) - 40% - 95%,
  • pure ethanol - 95% - 97.5% [10].

A US standard drink contains 12 grams of pure ethanol - approximately the amount found in one 12 oz. beer, one 5 oz. glass of wine, or one 1.5 oz. 'shot' of hard liquor [10].

  • beer - 12 oz. (1 can or bottle),
  • wine - 5 oz. (1 glass),
  • spirits - 1.5 oz. (1 shot) [10].

In general, it takes the average drinker's body one hour to metabolise one drink. As the amount of alcohol consumed exceeds the body's ability to metabolise it, the user's BAC increases, and he or she begins to feel the effects of alcohol intoxication. As one's BAC continues to increase, the user will experience different levels of intoxication [10].

Alcopops

Most of these have an ABV of 4% - 5.5% with a range of units from 1.5 - 1.75 per bottle. The most well-known brands are the alcoholic lemonades and there are also alcoholic colas, fruit flavoured drinks and those using spirits such as vodka and tequila [6].

Spirits

Most standard 700 ml bottles of whisky, vodka or rum have an ABV of around 40% containing 25 - 30 units of alcohol [6].

Wine

Most wines are produced with an ABV of around 10% - 13% in a standard 750ml bottle containing 7 - 10 units of alcohol. Wines from hotter climates such as Italian and Californian wines tend to be stronger at 12% - 13% ABV.

Fortified wines are stronger, with drinks like Buckfast and Eldorado being as strong as 17%. Sherry is usually produced with an ABV of 15% - 20% giving around 13 - 14 units of alcohol for a typical 750ml bottle [6].

Cider

This varies in strength from the low alcohol varieties such as Strongbow LA with an ABV of just 0.9% up to the white ciders' with an ABV of around 8.4%. A can of one of the stronger ciders contains around 2.5 - 3.5 units of alcohol [6].

Beer and lager

Most popular types of bitter beer are around 3.5% - 4.1% ABV - giving around 2 - 2.25 units for a pint and 1.5 - 1.75 units for a 440 ml can.

The strength of lager beers can vary widely and ranges from very low strength drinks like Barbican (0.02% ABV) to super strong' lagers at anything up to 10%. But like bitter beers, many popular lagers are around 3.5% - 4% ABV providing 1.5 - 1.75 units in a 440ml can and 2 - 2.25 units in a pint.

A different type of alcohol produced from wood (methyl alcohol) is used in methylated spirits and surgical spirit. Some alcoholics ('meths' drinkers) drink this type of alcohol because it is cheap. Methyl alcohol is poisonous and can cause blindness, coma and death.

Unlike most drugs, alcohol has food value and supplies calories. One gram of alcohol supplies seven calories, almost twice the number of calories as one gram of carbohydrate. A pint of beer can supply as many calories as six slices of bread. Beer provides very little protein or vitamin and distilled spirits provide none at all [6].

How long do its effects last?

Onset of effects

  • 15 - 30 minutes [11].

Come up

  • 15 - 20 minutes [11].

Peak

  • 30 - 90 minutes [11].

Offset

  • 45 - 60 minutes [12].

Duration of effects

  • 90 - 180 minutes [12].

Coming down

  • 45 - 60 minutes [11].

After-effects

Pharmacology

Alcohol acts specifically in the central nervous system to depress signals. They do this through their actions on the excitatory (stimulating) and inhibitory (depressant) chemicals GABA and glutamate, respectively.

At low doses it seems to work by activating the excitatory receptor (NMDA) and chemical (glutamate) in the brain and acting in areas related to memory, pleasure and thinking.

Higher dose seem to slow down (depress) the central nervous system by activating the inhibitory receptors related to the release of the chemical GABA. This leads to poor coordination, memory loss, blurred vision etc.

Very high doses can cause vomiting, coma and death through respiratory failure [3].

Lethal dosage

Death from ethanol consumption is possible when blood alcohol levels reach 0.4%. A blood level of 0.5% or more is commonly fatal. Levels of even less than 0.1% can cause intoxication with unconsciousness often occurring at 0.3% - 0.4% [13], [12].

A fatal dose is around 500mg of alcohol per 100ml of blood [6].

Alcohol poisoning

Alcohol poisoning occurs when there is so much alcohol in a person's bloodstream that areas of the brain controlling basic life-support systems - such as breathing, heart rate, and temperature control - begin to shut down [14].

Symptoms of alcohol poisoning include -

  • confusion,
  • difficulty remaining conscious,
  • vomiting,
  • seizures,
  • breathing problems,
  • slow heart rate,
  • clammy skin,
  • dulled responses, such as no gag reflex (which prevents choking),
  • extremely low body temperature,
  • death [14].

If you suspect someone has alcohol poisoning, call 999 and get medical help immediately. Cold showers, hot coffee, or walking will NOT reverse the effects of alcohol overdose and could actually make things worse [14].

Alcohol blackout

An alcohol blackout is a gap in a person's memory for events that took place while he or she was drinking. When a blackout happens, a person's brain does not create memories for these events as they are happening. For people who have had a blackout, it can be frightening to wake up the next day and not remember what they did the night before [14].

Tolerance

Tolerance to many of the effects of alcohol develops with prolonged and repeated use. This results in users having to administer increasingly large doses to achieve the same effects. After that, it takes about 3 - 7 days for the tolerance to be reduced to half and 1 - 2 weeks to be back at baseline (in the absence of further consumption). Alcohol presents cross-tolerance with all GABAgenic depressants, meaning that after the consumption of alcohol all depressantss will have a reduced effect [12].

Official guidelines

The UK Chief Medical Officers advise that an alcohol-free childhood is the healthiest and best option [2]. However, if young people drink alcohol -

  • It should not be until at least the age of 15 years.
  • If young people aged 15 to 17 years consume alcohol, it should always be with the guidance of a parent or carer or in a supervised environment.
  • Parents and young people should be aware that drinking, even at 15 or older, can be hazardous to health and that not drinking is the healthiest option for young people.
  • If 15 to 17 year olds do consume alcohol, they should do so infrequently and certainly on no more than one day a week.
  • Young people aged 15 to 17 years should never exceed recommended adult daily limits and, on days when they drink, consumption should usually be below these levels [2].

For adults, the UK Chief Medical Officers advise that there is also no completely safe level of drinking, but that by sticking within their recommended guidelines, people can lower the risks of harming their health.

Adults are safest not to drink regularly more than 14 units per week, to keep health risks from drinking alcohol to a low level. And if they do drink as much as 14 units per week, it is best to spread this evenly over 3 days or more. If they want to cut down the amount they're drinking, a good way to help achieve this is to have several drink-free days each week.

Alcohol comes in a whole range of drinks with different alcoholic strengths, colours and tastes. Also, unusual forms of alcohol - powder, vapour and spray - have been developed by some companies.

Alcohol often has labels with useful information, such as how many units are in the drink. All labels are required by law to display the strength of the drink (alcohol by volume, or ABV).

Spirits usually contain a higher level of alcohol than wine or lager and are normally drunk in smaller measures.

'Alcopops' and ready-to-drink 'mixers' may not seem to be strong drinks but they may contain more alcohol than typical bottles or cans of beer or cider.

Prices vary depending on what you drink and the quality, for instance a premium whisky or older bottle of wine is more expensive than a pint of beer.

There is no completely safe level of drinking, but by sticking within these guidelines, you can lower your risk of harming your health [2].

  • Men and women are advised not to regularly drink more than 14 units a week.
  • Don't 'save up' your units to use in one or two days. If you do drink as much as 14 units in a week you should spread this out over three or more days [2].

If you want to cut down how much you're drinking, a good way to help achieve this is to have several drink-free days each week [2].

Mode of use

Alcohol is consumed in drinks such as beer, wine and liquor [4].

Signs of alcoholism

  • thoughts and actions consumed by alcohol,
  • lack of interest in regular responsibilities,
  • work and school production is negatively effected, possible loss of employment,
  • legal repercussions to actions while intoxicated,
  • issues within relationships with friends and family due to your drinking,
  • health issues,
  • inability to stop drinking on your own,
  • financial difficulties due to drinking alcohol [15].

Effects

The effects of alcohol on behaviour depend on the level of alcohol in the blood -

  • Low blood-alcohol-concentration will depress parts of the brain involved in inhibition, making the user more animated and social. It may also lift your mood, but even at low levels alcohol can still affect coordination and judgement.
  • Higher concentrations of alcohol will begin to seriously hamper coordination, memory and judgement. Alcohol also depresses the ability to regulate emotion, which is why intoxicated people can become emotional or aggressive.
  • High enough concentrations of alcohol in the blood will cause users to become woozy and they may pass out. A potentially fatal concentration of alcohol in the blood will depress areas of the brain involved in breathing, causing breathing to slow dramatically and eventually stop [1].

Alcohol also causes the user to urinate more, causing dehydration. Following heavy use of alcohol the user may experience a 'hangover', which typically is experienced the morning after (although a hangover can last longer). Effects of a hangover can include: nausea and vomiting, headache, thirst, sensitivity to light and noise, diarrhoea, low mood and anxiety. People can generally be described as not being at their best on a hangover, and studies have found things like memory to be worse during a hangover [1].

Alcohol in a social context often helps people to be happier and more confident. Tipsy people can be chatty and giggly, although some may become withdrawn. Alcohol often makes people say and do things they normally wouldn't (reduces inhibitions). When people aren't at bars, clubs and parties, many people consume alcohol for its calming effects, for example, wine with an evening meal. Many people say they enjoy alcoholic drinks for the taste, rather than using it as a drug. However, the taste of alcoholic drinks is usually unpleasant to people when they first try them and later enjoyment of the taste may be a learned association with the drug. After a couple of drinks, people start to lose the ability to concentrate and think straight [1].

  • A small amount can reduce feelings of anxiety and reduce inhibitions, which can help you feel more sociable.
  • It can exaggerate whatever mood you're in when you start drinking.
  • The short-term effects of alcohol can last for a day or two, depending on how much you drank, including any hangover.
  • Long-term effects include damage to the brain, body and its organs. This can take years to develop and can lead to a wide range of serious health problems, like cancers, that you may not realise are due to alcohol [2].

Remember that the more you have of a drink, and the stronger the drink, the more units you are drinking [2].

People who drink are affected even before they show signs of being drunk, especially when it comes to decision-making abilities.

At first, alcohol causes people to feel upbeat and excited. But this is temporary and they shouldn't be fooled.

If drinking continues, the effects on the body - and the potential risks - multiply [14]. Here's what can happen -

  • inhibitions and memory - People may say and do things that they will regret later, or possibly not remember at all. Inhibitions are lost - leading to poor decision making,
  • decision-making skills - When they drink, individuals are more likely to be impulsive. They may be at greater risk for having an alcohol-related traffic accident, getting into fights, or making unwise decisions about sex,
  • coordination and physical control - When drinking leads to loss of balance, slurred speech, and blurred vision, even normal activities can become more dangerous,
  • death - Drinking too much alcohol can also lead to death. If people drink too much, they will eventually get sleepy and pass out. Reflexes like gagging and breathing can be suppressed. That means they could vomit and choke, or stop breathing completely [14].

And finally, it's easy to misjudge how long alcohol's effects last. Alcohol continues to affect the brain and body long after the last drink has been finished. Even after someone stops drinking, alcohol in the stomach and intestine continues to enter the bloodstream, impairing judgment and coordination for hours [14].

The effects of drinking depend on a variety of factors, including, but not limited to the -

  • amount of alcohol consumed,
  • time taken to consume it,
  • individual's gender, weight, body size, and percentage of body fat,
  • amount of food in the stomach,
  • use of medications, including non-prescription drugs,
  • mindset of the individual at the time of consumption,
  • setting in which the drinking takes place [16].

Short-term effects

The short-term effects of drinking alcohol can cause numerous adverse effects on the user, including -

  • slowed reaction times and reflexes,
  • poor motor coordination,
  • blurred vision,
  • slurred speech,
  • lowered inhibitions,
  • increase in risk behaviour,
  • lowered reasoning ability,
  • impaired judgment,
  • memory loss,
  • confusion,
  • anxiety,
  • restlessness,
  • slowed heart rate,
  • reduced blood pressure,
  • slowed breathing rate,
  • heavy sweating,
  • nausea,
  • vomiting,
  • dehydration,
  • coma,
  • death from respiratory arrest [17], [16].

Long-term effects

Over time, heavy drinking can cause permanent damage to the user's body and brain. Several factors affect the severity and extent of this damage, including the drinker's age and gender as well as the duration and extent of abuse [16].

The physical damage caused by sustained alcohol abuse includes -

  • liver damage,
  • accumulation of fat in the liver,
  • cirrhosis - heavy scarring of the liver prevents blood flow; usually fatal,
  • alcoholic hepatitis - swelling of liver cells, causing blockage; sometimes fatal,
  • liver cancer,
  • heart damage,
  • high blood pressure,
  • coronary disease - narrowing of the arteries, leading to heart attack or death,
  • enlarged heart,
  • irregular heartbeat - can lead to heart attack or death,
  • decreased blood flow to the arms and legs,
  • stroke - blocked blood flow to the brain.
  • brain damage,
  • lowered cognitive abilities,
  • destruction of brain cells - producing brain deterioration and atrophy,
  • mental disorders - increased aggression, antisocial behavior, depression, anxiety,
  • damage to sense of balance - causing more accidental injuries,
  • bone damage,
  • bone growth - that normally takes place in teenage years is stunted,
  • osteoporosis - severe back pain, spine deformity, increased risk of fractures,
  • pancreas damage,
  • pancreatitis - inflammation of the pancreas, causing abdominal pain, weight loss, and sometimes death,
  • cancer,
  • alcoholism - increases a person's chances of developing a variety of cancers of the pancreas, liver, breasts, colon, rectum, mouth, pharynx, and oesophagus,
  • sexual problems,
  • reduced sperm count and mobility - as well as sperm abnormality,
  • menstrual difficulties - irregular/absent cycles, and decreased fertility,
  • early menopause,
  • birth defects,
  • drinking alcohol during pregnancy - can cause permanent, severe damage, by putting the child at risk for Fetal Alcohol Syndrome [17], [16].

Physical effects

  • muscle relaxation,
  • physical euphoria,
  • skin flushing,
  • appetite enhancement,
  • appetite suppression,
  • motor control loss,
  • pain relief,
  • respiratory depression,
  • sedation,
  • tactile suppression,
  • dehydration,
  • difficulty urinating,
  • dizziness,
  • frequent urination,
  • headaches,
  • increased blood pressure,
  • increased perspiration,
  • nausea,
  • physical fatigue,
  • temperature regulation suppression,
  • temporary erectile dysfunction [12].

Cognitive effects

  • cognitive euphoria,
  • compulsive redosing,
  • delusions,
  • depression,
  • ego inflation,
  • empathy, love, and sociability enhancement,
  • increased music appreciation,
  • amnesia,
  • analysis suppression,
  • anxiety suppression,
  • cognitive fatigue,
  • creativity suppression,
  • disinhibition,
  • focus suppression,
  • information processing suppression,
  • language suppression,
  • sleepiness,
  • thought deceleration,
  • thought disorganisation [12].

Visual effects

  • after images,
  • acuity suppression,
  • double vision,
  • pattern recognition suppression [12].

Auditory effects

  • auditory enhancement,
  • auditory suppression [12].

After effects

  • appetite suppression,
  • cognitive fatigue and physical fatigue,
  • dehydration,
  • nausea,
  • headaches,
  • information processing suppression,
  • sleep paralysis - some users experience sleep paralysis after alcohol consumption; it is usually associated with consistent usage,
  • thought deceleration [12].

Positive effects

  • relaxation,
  • mood lift, happiness, giddiness,
  • increased sociability,
  • lowered inhibitions & reduced social anxiety,
  • analgesia [18].

Neutral effects

  • slurred speech,
  • flushed skin,
  • drowsiness, sleepiness,
  • nystagmus, difficulty focusing eyes,
  • changed (often increased) response to sexual stimuli,
  • tolerance with repeated use within a few days,
  • changed aesthetic appreciation - normally beautiful things can seem ugly, things normally seen as ugly judged beautiful,
  • beer goggles - others appear more attractive,
  • mild visual distortions at high doses [18].

Negative effects

Negative side-effects increase with higher doses [18].

  • decreased coordination,
  • nausea, vomiting (vomiting while unconscious can be fatal),
  • dehydration,
  • reduced impulse control,
  • emotional volatility (anger, violence, sadness, etc),
  • reduced ability to attain/maintain erection in most males,
  • increased difficulty in achieving orgasm in some females,
  • frequent urination (more with beer or wine), diuretic effect,
  • dizziness and confusion,
  • blackouts and memory loss at high doses,
  • coma and death at extreme doses,
  • brain and liver damage (cirrhosis) with heavy use,
  • lowered inhibitions and increased confusion can lead to unwanted and *negative sexual encounters (date rape),
  • hangover, lasting 1 - 36 hours, from mild to severe after heavy use,
  • foetal damage in pregnant women at high dose or frequency [18].

Overdose or alcohol poisoning

  • person is passed out,
  • extremely difficult to wake,
  • cold, clammy, pale or bluish skin,
  • slow breathing,
  • irregular breathing,
  • vomiting - person vomits while passed out [16].

Alcohol-related health problems

  • premature aging
  • heartburn,
  • nausea,
  • gastritis,
  • ulcers
  • poor digestion
  • inflammation of the intestines
  • malnutrition
  • water retention
  • weakened vision
  • skin disorders
  • korsakoff's syndrome - amnesia and delirium after long-term alcohol abuse [16].

What are the long-term effects of alcohol on health and wellbeing?

Health harms

Whether addicted or not, drinking large amounts of alcohol causes or increases the risk of diseases in almost all parts of the body, including the brain. The harms of drinking too much alcohol are often wrapped up with other health problems, such as a bad diet, and social problems such as poverty and unemployment. Alcohol causes damage to the heart, pancreas and other organs. The liver, which works to detoxify the body from alcohol, is often worst affected. The death toll from liver disease has been steadily rising over the last few decades, which can largely be put down to alcohol use.

Alcohol is also a carcinogen. It causes or increases the risk of many types of cancer including common ones like breast cancer, although moderate drinking seems to reduce the risk of a few rarer cancers. Alcohol can also cause diabetes, hormonal imbalances and sexual dysfunction.

Alcohol is particularly toxic to the brain. Women who drink heavily while they are pregnant may cause severe harm to the foetus, especially to the foetus' developing brain. This is called foetal alcohol syndrome and in severe cases this causes profound intellectual disabilities and behavioural problems. In adults, alcoholism causes brain shrinkage and is the second biggest cause of dementia. Long-term alcoholism with malnourishment can cause Wernicke-Korsakoff syndrome, which can leave permanent brain damage with dementia and amnesia.

About a quarter of people with alcohol dependence suffer from mental illnesses. However, it is often difficult to tell whether some mental health conditions are caused by alcohol, or whether people drink to try to deal with their conditions. Sometimes both can be true, creating a vicious circle. For example, many people with alcohol dependence may be self-medicating for their anxiety and depression, which can in turn add to their condition [1].

Damage to employment, families and communities

An unhealthy relationship with alcohol can impact others aside from the drinker. All addictions can make it difficult to hold down a job, and can be damaging to relationships. It can be very hard to live with an alcoholic or binge drinker. Binge drinking is associated with anti-social behaviour that can fracture families and communities. Alcoholism like any addiction takes up time and resources, making it very difficult for homeless and vulnerably housed people to improve their situation. It can be a serious obstacle to employment and rehabilitation [1].

Association with crime and antisocial behaviour

When people are under the influence of alcohol, especially after binge drinking, they are often less able to control violent impulses or act with good judgement. The majority of assaults on young people which lead to hospital treatment are alcohol-related, and roughly half of domestic violence occurs after the perpetrator has been drinking. Alcohol is a major factor in the maltreatment of children. Drunkenness, even when non-violent, uses up police time, accounting for most arrests that occur at night. Very drunk offenders are particularly time-consuming, as they are more likely to be disruptive and uncooperative, and they need to be checked every few minutes to ensure their safety after arrest.

Being drunk also makes people more likely to be victims of crime. Whilst sexual assault can never be blamed on the victim and most rape victims are not drunk, in assaults which are facilitated by drugs alcohol is almost always present, and is often the only intoxicant involved [1].

Signs of intoxication

  • clumsiness,
  • difficulty walking,
  • slurred speech,
  • sleepiness,
  • poor judgment,
  • dilated pupils [19].

Signs and symptoms of alcohol abuse or problem drinking

  • repeatedly neglecting your responsibilities at home, work, or school because of your drinking. For example, performing poorly at work, flunking classes, neglecting your kids, or skipping out on commitments because you're hung over.
  • using alcohol in situations where it's physically dangerous, such as drinking and driving, operating machinery while intoxicated, or mixing alcohol with prescription medication against doctor's orders.
  • experiencing repeated legal problems on account of your drinking. For example, getting arrested for driving under the influence or for drunk and disorderly conduct.
  • continuing to drink even though your alcohol use is causing problems in your relationships. Getting drunk with your friends, for example, even though you know your wife will be very upset, or fighting with your family because they dislike how you act when you drink.
  • drinking as a way to relax or de-stress. Many drinking problems start when people use alcohol to self-soothe and relieve stress. Getting drunk after every stressful day, for example, or reaching for a bottle every time you have an argument with your spouse or boss [20].

Alcoholism warning signs

  • getting drunk repeatedly,
  • continuing to drink when others have called it quits,
  • comments and attitudes of peers indicating concern on their part for your drinking,
  • drinking due to a compelling need for alcohol when lonely, depressed, anxious, etc,
  • experiencing blackouts,
  • feeling more comfortable under the influence of alcohol than when sober,
  • increasing tolerance and decreased hangover symptoms,
  • out-of-character behaviour,
  • a pattern of negative consequences associated with alcohol use,
  • rationalising/excusing the need for alcohol and becoming defensive when others express concern [16].

Hangovers

  • headache,
  • diarrhoea and nausea,
  • tiredness and trembling,
  • increased heart rate and blood pressure,
  • dry mouth and eyes,
  • trouble concentrating,
  • anxiety,
  • restless sleep [21], [1].

Risks

Alcohol impairs judgment and drunk people are more likely to be reckless and commit violent and sexual assaults. More than 40% of all intentionally caused injuries would not have occured without alcohol. Additionally, serious injuries or deaths can result from the loss of judgment and coordination caused by alcohol. House fires (e.g. from drunken cooking attempts, or falling asleep whilst smoking), and car accidents (from drunk drivers or drunk pedestrians crossing the road) are often linked to alcohol intoxication.

If someone has passed out from drinking too much alcohol it is possible for them to choke on their own vomit. Large amounts of alcohol can also cause a person to fall into a coma-like state or stop breathing. The level of risk increases the more drunk you are, which means that the most important way to reduce your chance of being harmed is by drinking less. Many more harms are associated with long-term use of alcohol [1].

Drinking alcohol involves risks, particularly if you drink excessively on a single occasion or drink regularly over time. Alcohol contributes to all kinds of problems in Britain, from violent crime to domestic violence to car-related deaths to missing work and unemployment [2]. Here's what it could do to you in the short and long-term -

  • One drink too many can leave you feeling out of control - slurring your words, losing your balance, having accidents and vomiting.
  • Heavy drinking can make you mouthy, argumentative and aggressive. Sometimes people turn into a nasty drunk or it affects them in other ways they don't like.
  • Alcohol can make you take risks that you normally wouldn't take when you're sober, such as unprotected sex.
  • Drinking too much alcohol can leave you at risk of being taken advantage off or of being hurt by others.
  • Drinking regularly, especially above the recommended guidelines, can cause or contribute to illnesses such as high blood pressure, liver damage, stomach cancer, breast cancer and stroke.
  • Far too much alcohol on a single occasion can lead to alcohol poisoning which could put you in a coma or even kill you.
  • The overall health risks are broadly similar for men and women - on average, short term risks are greater for men and long term risks are greater for women.
  • There are short-term risks like injuries and accidents which can happen when you are drinking heavily. These can include head injuries, fractures and scars, and can sometimes be fatal. There are other short-term risks such as alcohol poisoning.
  • Long-term risks come from regularly drinking alcohol over a long time (over 10 to 20 years or more). Then the risks of getting different diseases increase and can lead to illnesses, such as cancer, stroke, heart disease, liver disease, and damage to your brain and nervous system [2].

More information about alcohol can be found at -

The scientific name for the alcohol in drinks is ethanol or ethyl alcohol. Other types of alcohol, such as methanol and butanol, are much more toxic than ethanol and should not be consumed by humans, as they can cause serve liver damage, blindness and even death.

Although these toxic forms of alcohol are sometimes found in counterfeit alcoholic drinks, the vast majority of alcohol brought from legitimate sources won't contain any impurities.

Counterfeit alcoholic drinks tend to be sold in places you wouldn't normally buy alcohol, such as car boot sales, and sold at low prices. Sometimes, a clue to knowing that an alcoholic drink is counterfeit is its labelling and packing - there maybe spelling mistakes, holographic labels aren't holographic, etc [2].

Alcohol and gender

Women are more vulnerable than men to the negative effects of drinking. Women have less total body water and less alcohol dehydrogenase - the stomach enzyme involved in metabolising alcohol. As a result, the female body takes longer to break down alcohol. Also, the fluctuations in hormone levels that women experience during the menstrual cycle can make a woman more susceptible to the effects of drinking. And because alcohol increases oestrogen levels, birth control pills or other medications containing oestrogen can increase intoxication [22].

Two-thirds of alcoholics are men; however, the negative effects of heavy drinking are more severe for women. Female alcoholics are more likely to suffer alcohol-related damages and diseases than alcoholic men [17], [16].

The path from alcohol abuse to alcoholism

Not all alcohol abusers become full-blown alcoholics, but it is a big risk factor. Sometimes alcoholism develops suddenly in response to a stressful change, such as a breakup, retirement, or another loss. Other times, it gradually creeps up on you as your tolerance to alcohol increases. If you're a binge drinker or you drink every day, the risks of developing alcoholism are greater [20].

Short-term

  • tolerance,
  • overdose,
  • accidents (drunk-driving),
  • unconsciousness,
  • coma,
  • death [5].

Long-term

  • dependence,
  • withdrawal symptoms,
  • significant permanent damage to the brain and other organs - heart, liver, stomach - that can be fatal [5].

Addiction

Can you get addicted

Alcohol dependence, often called alcoholism, is common. Dependence on alcohol means that the user has lost some or all control over their use of alcohol and are likely to suffer withdrawal effects if they don't drink. This is more common in men, although women who are alcohol dependent usually suffer more severe harms as a result of alcoholism.

Not everyone who drinks alcohol is equally at risk of becoming dependent. Drinking from an early age and using alcohol as a tool to blot out stress and anxiety are just some factors associated with drinking too much and becoming dependent. Alcoholism can run in families, due to both genetic reasons and the influences people are exposed to. Traumatic experiences in early life, such as abuse, increase the chances of becoming alcohol dependent [1].

Some people's drinking gradually gets out of control and if they regularly drink above the recommended guidelines, they're at particularly high risk of harming their health. For some people, it also leads to them becoming dependent on alcohol.

Psychological and physical dependence on alcohol can creep up on you. Your tolerance to alcohol gradually increases the more you drink, so you may find that over time that you need more alcohol to get the same effect, you may seem to be getting better at holding your drink when that's really a sign of a developing problem.

For people who are more dependent on alcohol, the withdrawal symptoms after they stop drinking can be severe. In some cases the withdrawal symptoms can be fatal, so a person may require medical treatment because of this risk of death. Typically, the symptoms include sweating, shaking, nausea and retching and high levels of anxiety. Some people can develop hallucinations or fits, or occasionally life-threatening delirious states [2].

Is your drinking a problem?

You may have a drinking problem if you -

  1. Feel guilty or ashamed about your drinking.
  2. Lie to others or hide your drinking habits.
  3. Have friends or family members who are worried about your drinking.
  4. Need to drink in order to relax or feel better.
  5. 'Black out' or forget what you did while you were drinking.
  6. Regularly drink more than you intended to [20].

Alcohol dependence

Chronic excess alcohol intake, or alcohol dependence, can lead to a wide range of -

  • neuropsychiatric or neurological impairment,
  • cardiovascular disease,
  • liver disease,
  • malignant neoplasms [23], [12]

The psychiatric disorders which are associated with alcoholism include -

  • major depression,
  • dysthymia,
  • mania,
  • hypomania,
  • panic disorder,
  • phobias,
  • generalised anxiety disorder,
  • personality disorders,
  • schizophrenia,
  • suicide,
  • neurologic deficits (e.g., impairments of working memory, emotions, executive functions, visuospatial abilities, gait and balance),
  • brain damage [23], [12].

Alcohol dependence is associated with

  • hypertension,
  • coronary heart disease,
  • ischaemic stroke,
  • cancers of the respiratory system, the digestive system, liver, breast and ovaries [23], [12].

Heavy drinking is associated with liver disease, such as cirrhosis [23], [12].

Dangerous interactions

Alcohol can be very dangerous to take in combination with other drugs, especially other depressant drugs such as barbiturates, heroin, methadone or tranquillisers and drugs such as antidepressants, anti-histamines and painkillers. Mixing these drugs and alcohol has led to fatal overdoses [6].

Although many drugs are safe on their own, they can become dangerous and even life-threatening when combined with other substances. The list below contains some common potentially dangerous combinations, but may not include all of them. Certain combinations may be safe in low doses of each but still increase the potential risk of death. Independent research should always be done to ensure that a combination of two or more substances is safe before consumption [12].

  • Depressants (1,4-Butanediol, 2-methyl-2-butanol, barbiturates, benzodiazepines, GHB/GBL, methaqualone, opioids, phenothiazines [13]) - This combination can result in dangerous or even fatal levels of respiratory depression. These substances potentiate the muscle relaxation, sedation and amnesia caused by one another and can lead to unexpected loss of consciousness at high doses. There is also an increased risk of vomiting during unconsciousness and death from the resulting suffocation. If this occurs, users should attempt to fall asleep in the recovery position or have a friend move them into it.
  • Dissociatives - This combination can result in an increased risk of vomiting during unconsciousness and death from the resulting suffocation. If this occurs, users should attempt to fall asleep in the recovery position or have a friend move them into it.
  • Stimulants - It is dangerous to combine alcohol, a depressant, with stimulants due to the risk of excessive intoxication. Stimulants decrease the sedative effect of alcohol, which is the main factor most people consider when determining their level of intoxication. Once the stimulant wears off, the effects of alcohol will be significantly increased, leading to intensified disinhibition as well as other effects. If combined, one should strictly limit themselves to only drinking a certain amount of alcohol per hour. This combination can also potentially result in severe dehydration if hydration is not monitored. It also interacts with cocaine in vivo to produce cocaethylene, another psychoactive substance [24].
  • MAOIs - This combination can result in dangerous reactions through the way in which tyramine, a chemical commonly found in alcoholic beverages, causes increased blood pressure [12].

Withdrawal

Being addicted to alcohol (alcoholism, alcohol dependence) makes people particularly vulnerable to the many health harms that alcohol can cause. Addiction changes a person's priorities, which can be devastatingly disruptive to the lives and wellbeing of the addicted person and their families. People who are worried about alcohol addiction can get help and support by visiting their doctor.

People who are alcoholic find it very difficult to give up. Mildly addicted people suffer psychologically when they try quitting and may get cravings and feel anxious and miserable without drinking. Addicted drinkers become physically as well as psychologically reliant on alcohol. Physical reliance on alcohol means that a person's body has adapted to having alcohol in it, and so removing the alcohol causes physical withdrawal symptoms. Quitting can cause flu-like or hangover-like withdrawal symptoms for about 3 days. Withdrawal from more severe alcoholism can have dangerous consequences, especially episodes of delirium tremens, which is potentially fatal. This includes shaking, hallucinations and a racing heart.

Withdrawal for severe alcohol addiction should only be attempted with medical help [1].

When physical dependence has developed, withdrawal symptoms may occur if a person suddenly stops their usage. The severity of withdrawal can vary from mild symptoms such as sleep disturbances and anxiety to severe and life-threatening symptoms such as delirium, hallucinations, and autonomic instability.

Withdrawal usually begins 6 to 24 hours after the last drink [25]. It can last for up to one week [26]. To be classified as alcohol withdrawal syndrome, patients must exhibit at least two of the following symptoms: increased hand tremors, insomnia, nausea or vomiting, transient hallucinations (auditory, visual or tactile), psychomotor agitation, anxiety, tonic-clonic seizures, and autonomic instability [27], [12].

The severity of symptoms is dictated by a number of factors, the most important of which is degree of alcohol intake, length of time the individual has been using alcohol, and previous history of alcohol withdrawal [27]. Symptoms are also grouped together and classified -

  • Alcohol hallucinosis - Patients have transient visual, auditory, or tactile hallucinations but are otherwise clear [27].
  • Withdrawal seizures - Seizures occur within 48 hours of alcohol cessation and occur either as a single generalized tonic-clonic seizure or as a brief episode of multiple seizures [28].
  • Delirium tremens - Hyperadrenergic state, disorientation, tremors, diaphoresis, impaired attention/consciousness, and visual and auditory hallucinations [27] usually occur 24 - 72 hours after alcohol cessation. Delirium tremens is the most severe form of withdrawal and occurs in 5% to 20% of patients experiencing detoxification and 1/3 of patients experiencing withdrawal seizures [28].

If your brain has adjusted to your heavy drinking habits, it takes time for your brain to adjust back. Alcohol withdrawal symptoms occur in a predictable pattern after your last alcohol drink [29]. Not all symptoms develop in all patients -

  • Tremors (shakes) - These usually begin within 5 to 10 hours after the last alcohol drink and typically peak at 24 to 48 hours. Along with tremors (trembling), you can have a rapid pulse, an increase in blood pressure, rapid breathing, sweating, nausea and vomiting, anxiety or a hyper-alert state, irritability, nightmares or vivid dreams, and insomnia.
  • Alcohol hallucinosis - This symptom usually begins within 12 to 24 hours after your last drink, and may last as long as 2 days once it begins. If this happens, you hallucinate. It is common for people who are withdrawing from alcohol to see multiple small, similar, moving objects. Sometimes the vision is perceived to be crawling insects or falling coins. It is possible for an alcohol withdrawal hallucination to be a very detailed and imaginative vision.
  • Alcohol withdrawal seizures - Seizures may occur 6 to 48 hours after the last drink, and it is common for several seizures to occur over several hours. The risk peaks at 24 hours.
  • Delirium tremens - Delirium tremens commonly begins two to three days after the last alcohol drink, but it may be delayed more than a week. Its peak intensity is usually four to five days after the last drink. This condition causes dangerous shifts in your breathing, your circulation and your temperature control. It can cause your heart to race dangerously or can cause your blood pressure to increase dramatically, and it can cause dangerous dehydration. Delirium tremens also can temporarily reduce the amount of blood flow to your brain. Symptoms can include confusion, disorientation, stupor or loss of consciousness, nervous or angry behavior, irrational beliefs, soaking sweats, sleep disturbances and hallucinations [29].

Symptoms of alcohol withdrawal typically improve within five days, though a small number of patients may have prolonged symptoms, lasting weeks [29].

Many individuals who have become physically dependent upon alcohol experience withdrawal symptoms when alcohol use is abruptly stopped [8]. The symptoms of withdrawal can be managed through proper detox under the careful eye of medical professionals and may include -

  • nausea and vomiting,
  • depression,
  • anxiety,
  • shaking or trembling,
  • extreme sweating,
  • insomnia,
  • headache,
  • fatigue,
  • loss of appetite,
  • intense irritability,
  • hallucinations,
  • high fever,
  • confusion,
  • seizures,
  • agitation [8],
  • easily excited,
  • rapid emotional changes,
  • unclear thoughts,
  • bad dreams,
  • paleness,
  • heart palpitations,
  • enlarged, dilated pupils,
  • abnormal movements,
  • tremors [15].

Prognosis

Alcohol withdrawal is common, but delirium tremens only occurs in 5% of people who have alcohol withdrawal. Delirium tremens is dangerous, killing as many as 1 out of every 20 people who develop its symptoms.

After withdrawal is complete, it is essential that you not begin drinking again. Alcohol treatment programs are important because they improve your chances of successfully staying off of alcohol. Only about 20% of alcoholics are able to abstain from alcohol permanently without the help of formal treatment or self-help programs such as Alcoholics Anonymous (AA). Of people who attend AA, 44% of those who remain free of alcohol for 1 year probably will remain abstinent for another year. This figure increases to 91% for those who have remained abstinent and have attended AA for 5 years or more.

On average, an alcoholic who doesn't stop drinking can expect to decrease his or her life expectancy by at least 15 years [29].

Harm Reduction

The aim of harm reduction thinking in alcohol intake is to reduce the negative consequences that drinking may have on you both physically and mentally [3].

  • Ask yourself why you drink? Do you feel insecure in company? Does it help you forget trauma? If the answer to any of this is an emphatic 'yes' then you may find you need some help with your drinking. Even if you know that alcohol makes you and many others feel more confident and less anxious, your drinking could be masking a problem that lead to a heavier more entrenched drinking pattern.
  • Mixing alcohol with some drug types is very dangerous and never beneficial. Alcohol is a central nervous system depressant and mixing it with anxiolytics like diazepam can cause respiratory depression.
  • Be aware that heavy drinking can cause you to alter perception and the boundaries of your usual behaviour and leave you vulnerable. If you do find you have drunk too much - tell a friend, keep near people you trust and don't travel home alone.
  • Many people suggest that it is better not to mix alcohol types particularly spirits.
  • Ask yourself if you have a ritual around your drinking that causes you not to question your drinking levels.
  • Change to a less potent regular drink (drink with a lower ABV)
  • Have something to eat before/ while drinking.
  • Taking your time over your drink.
  • Environment and company is important. Socialise outside heavy drinking circles. Competitive drinking can be risky and damaging. If you go out with a big crowd you may be expected to keep up.
  • Have alcohol free days. Hydrate yourself, water and fruit juice are good. Give your liver a day off!
  • Have a budget for the night - certain amount of cash/no cards.
  • Regular drinking at home is not advisable. Be aware when you are drinking alone.
  • Not playing or severely limiting getting involved in drinking games is sensible.
  • Have smaller measures - 25ml instead of double, small glass of wine instead of large.
  • Changing what you drink - type of drink/ less units e.g. 25ml vodka and tonic (1 unit) rather than large glass of wine (3 units) or 330ml bottle of Lager 3.8% (1.2 units) rather than pint of stronger lager (5%) (2.8 units).
  • Decide how much you are going to drink on an evening and stick to it - think about commitments the next day e.g. children, work, driving.
  • Alcohol can stay at detectable levels in your urine over night. This could get you a conviction, a ban or worse a prison sentence.
  • When you drive a car or motorbike after a heavy drinking bout, or immediately after a moderate drink you might be endangering not just your life but the lives of others. You may have to live with the consequences of an accident even if you did not cause it. Ask if it is worth the risk.
  • Think about how quickly you drink (more quickly than others?)
  • Publicans are not daft - salty snacks/nuts may make you thirsty and drink more.
  • Distance yourself from certain personal influences/ social situations where drinking is the norm.
  • That last 150 mls in the bottle isn't challenging you to drink it, if you don't feel like it - don't.
  • Do you notice other people are making comments about your drinking?
  • Do you get into fights /arguments? Is alcohol provoking an inner anger? Are you projecting your frustration onto others? [3].

Before

  • carry condoms,
  • eat before you drink and stay hydrated; it can reduce the chances of getting a hangover or accidentally drinking over your limit,
  • don't go out drinking alone, this will increase the chance of unpleasant experiences, unsafe circumstances, and risky behaviour [11].

During

  • don't drink and drive. as easy as it sounds, people still do it, causing hundreds of thousands of deaths per year,
  • avoid drinking out of impulse because of reaction to anger, this can lead to bad drinking episodes,
  • control the amount of drinks you have and the speed at which you drink them if you are susceptible to blackouts,
  • to control for diseases such as cancer, the best policy is to reduce the amount of alcohol that is taken. you can do this by counting the drinks you have in a day and set targets to reduce them,
  • avoid getting drinks spiked with other drugs by following simple steps [11].
  • pace yourself while drinking and know your limit,
  • avoid binge drinking,
  • drink some water,
  • call a taxi,
  • don't drink on an empty stomach,
  • avoid drinking when in a bad mood because a person may become more violent with less self-control,
  • try to drink from a shatter-proof glass to avoid injuries [30].

In an emergency or overdose

  • stay calm and try to not look anxious in front of the person,
  • before approaching or touching the person, explain what you intend todo in a direct and reassuring manner,
  • keep the person still and comfortable. don't let him/her walk alone,
  • do not administer any food, drink or medication - including aspirin or vitamins - which may cause stomach distress,
  • do not ridicule or threaten the person,
  • do not let the person sleep on his/her back. death from choking on inhaled vomit may result. Place the person on his/her side, with one arm extended above the head. keep a sober person nearby to watch for signs of trouble [11].

Important - remember, only time will help to sober a person who is intoxicated. Walking, black coffee or a cold shower will not help. Drink plenty of water to avoid dehydration, and reduce the hangover [11].

Seek medical attention if -

  • the person is unconscious and cannot be wakened,
  • breathing is irregular and/or shallow,
  • you suspect alcohol has been mixed with other drugs,
  • skin is clammy or pale,
  • blood in vomit [11].

After

Alcohol hangovers are considered to be worse than the day-after effects of nearly any other drug. Alcohol causes liver damage. Bad hangovers may indicate alcohol toxicity and should be avoided.

Occasional drinkers are more likely to get bad hangovers than regular ones.

They usually last for 1 - 36 hours [11].

The after-effects include -

  • headache,
  • bad mood,
  • thirst,
  • nausea, vomiting, and/or dry-heaves,
  • dizziness that becomes worse with movement,
  • loud noises and bright lights cause pain/discomfort,
  • inability to think clearly,
  • muscle fatigue and pain,
  • sweating and tremors [31], [11].

The best way to reduce hangover effects is to drink water before, during and after the night. However, this will not completely remove it as it isn't just caused by dehydration.

Regarding vitamin B supplements, there is no evidence that these actually 'cure' hangovers, although they may work as a placebo [11].

How to hydrate your body after drinking alcohol

Alcohol is a diuretic that causes you to lose more liquid than you consume. Many of the effects felt after a night of heavy drinking are related to dehydration, according to the 'Annals of Internal Medicine'. The best way to rehydrate your body is to drink plenty of water, although other fluids can serve the same function and reduce hangover symptoms, as well [32].

  • Drink 12 glasses of water following a night of consuming alcohol. Do not drink them all at once. Space the glasses out over a 12-hour period. Be careful not to drink too much water because that can cause other serious problems, such as water intoxication.
  • Drink a sports drink that contains electrolytes. Too much water when you are dehydrated can cause you to lose valuable electrolytes. Drinking sports drinks can help replace those electrolytes while hydrating your body.
  • Include ginger ale to help you hydrate your body. Dehydration and alcohol can cause nausea. Ginger helps to soothe an upset stomach while providing your body with the fluid it needs. The carbonation also can help with an upset stomach.
  • Drink a rehydration solution designed for sick children. Choose one that contains more electrolytes than sports drinks and can hydrate your body quickly [32].

Are there health conditions that make drinking alcohol more dangerous?

Yes. Alcohol causes and worsens many health conditions, especially in large amounts. If you have high blood pressure, cardiovascular disease, liver conditions, conditions that make you bleed easily, mental health issues, or any other serious health problems, alcohol may cause you greater harm than it does the average person. You may benefit from discussing this with your doctor.

Drinking whilst pregnant can cause harm to the foetus, particularly drinking heavily in the early stages. There is no proof that the occasional small drink when pregnant is harmful, although there has not been enough research to rule this out [1].

Testing

Minutes after drinking, alcohol can be measured in the blood. Levels of alcohol in the blood are easily measured for numerous reasons - the primary one being able to determine whether BAC has reached the legal limit.

Factors affecting blood alcohol content are food consumption, which will slow the absorption of alcohol into the bloodstream, size and weight of the drinker, and the amount consumed over a period of time. As amounts diminish and are expelled from the system, time is a critical factor in amounts of alcohol left in the blood [33].

Legal Limits in the UK

England and Wales drink driving limit

The maximum BAC limit in England and Wales is -

  • 35 micrograms of alcohol in 100 millilitres of breath, or
  • 80 milligrams of alcohol per 100 millilitres of blood, or
  • 107 milligrams of alcohol per 100 millilitres of urine [33].

In most other European countries, the limit is less, usually 50 milligrammes per 100 millilitres of blood [34].

Scotland drink driving limit

The alcohol limit for drivers in Scotland is different than in the rest of the UK. In December 2014 the limit was reduced to the following levels [34].

The maximum BAC limit in Scotland is -

  • 22 micrograms of alcohol in 100 millilitres of breath, or
  • 50 milligrams of alcohol per 100 millilitres of blood, or
  • 67 milligrams of alcohol per 100 millilitres of urine [33].

The Scottish Government say they have changed their drink drive limit to bring Scotland in line with most other European countries, to save lives and make Scotland's roads safer [35].

Data confirms that aggressive behaviours are present for drinkers who have a BAC of .08 or higher, thus reminding us that 40% - 60% of those jailed nationwide are convicted of crimes committed under the influence of alcohol at this rate or higher. This applies to employment, which can also be tested randomly, as well as performing publicly in any means, such as being arrested for 'public intoxication'. If there is any reason for law enforcement to intervene on someone in a public place, this limit will be legally enforced. Also when boating, swimming, motorcycles, skiing, and use of any kind of equipment that requires skillful operation, such as tools [36].

Methods of testing

Blood alcohol content is tested through a blood sample, via a saliva sample, a urine sample, or by breath analysis. Many factors determine the level of alcohol in a person's blood [36].

Ingestion/intoxication levels

Behavior is affected for everyone drinking alcohol, not just when an intoxication level is reached. While no set behavioural patterns occur, there are certain physical, emotional, and physiological effects that are common with alcohol consumption. The following information is taken from the table, Characteristic Effects of Different BAC Levels, by Dr. William R. Miller which illustrates how increasing amounts of alcohol affects behavioral patterns [36].

BAC Level Expected Behavioral Effects

  • .02-.04 - Relaxation, mild euphoria, relaxed social behaviours,
  • .055 - Any positive changes occur below this limit. Judgment altered...driving and motor abilities impaired, lack of coordination, information processing impaired, loss.
  • .06-.08 - of restraint, fantasies and motivation change.
  • .10 - Legally intoxicated in all states; reaction time slowed, memory impairment, increased risk of fatal car crash by 10x.
  • .12 - Vomiting may occur unless tolerance established.
  • .15 - Balance impaired, slurring of speech, fatal crash increases to 25x at this BAC; Major memory impairment 'blackout' normally occurs in this range (complete memory loss).
  • .20 - Memory does not transfer from short-term to long-term storage.
  • .30 - Double vision may occur; most drinkers become unconscious or fall asleep.
  • .45 - Lethal dose for 50% of adults; death occurs by alcohol poisoning - central nervous system inhibition of heart and breathing [36].

How many drinks until intoxicated?

Alcohol levels in the blood of the drinker are different, due to several factors. The amount consumed and the time period over which it is consumed. A person drinking four 1-unit drinks in 30 minutes will have higher blood alcohol content than a larger person consuming the same four drinks over 2 hours. Some people absorb alcohol more rapidly, due to having not eaten, having a smaller body mass, or other health factors, especially taking medications impacting the effects of alcohol and increasing behavioural aspects.

Women absorb alcohol differently than men, being inclined to reach higher blood levels of alcohol on less. Their capacity is less, even when the same size as the man. Absorption of alcohol happens faster and at a higher blood-alcohol ratio. Once believed to be due to body fat, it is now known women do not have the same number of digestive enzymes in their stomachs to help metabolise alcohol.

Highest rates of alcohol occur within an hour. It takes approximately one hour for each unit of alcohol consumed to be processed out of the drinker's body via the liver. While some of the alcohol is removed through respiration or the kidneys, 90% goes through the liver. Depending on the type of alcohol and amount, ridding the body completely takes several hours, of 100 proof liquor, 2.5 units of wine, or 10 units of beer [36].

Legality

There's often misunderstandings about alcohol and what's legal and what's not, so here's a quick guide to the law

  • It's illegal to give an alcoholic drink to a child under 5 except in certain circumstances (such as. under medical supervision)
  • Children aged under 16 must be accompanied by an adult in a pub or bar
  • It's against the law for anyone under 18 to buy alcohol in a pub, off-licence or supermarket or online
  • It's illegal for an adult to buy alcohol for someone aged under 18, except where that person buys beer, wine or cider for someone aged 16 or 17 to be drunk with a table meal while accompanied by a person over 18
  • Anyone over 18 can buy and drink alcohol legally in licensed premises in Britain. But, a lot of shops operate a scheme called Challenge 21 where if you look under 21 (or 25 in some places) and don't have proof of your age they will refuse to sell you alcohol [2].

The police have the power to stop a person and confiscate alcohol in a public place if they reasonably suspect the person to be aged under 18. Young people under 18 who persistently drink or are found possessing alcohol in public places may be prosecuted [2].

No person may buy or attempt to buy intoxicating liquor for consumption in a bar by a person under the age of 18; ages 16 - 17 may purchase beer, port, cider or perry in an eating area on licensed premises; under 16's can go into a restaurant where alcohol is served and at licensee's discretion may consume (but not purchase) alcohol bought by a parent or guardian as long as it is with a meal; under 14's can go into a pub with a children's certificate, but must be with an adult and stay in the garden or family room; ages 5 and over may consume alcohol at home with adult supervision. The Licensing Act 2003 abolished the old system of permitted hours for the sale of alcohol, allowing potentially 24 hour opening, seven days a week. Altogether there are over 200,000 licensed premises in the UK. These fall into two main categories - 'On' Licences - authorising the sale of alcohol for consumption on and off the premises. These licences may be for beer, cider and wines or beer, cider, wines and spirits. On-licensed premises include pubs and clubs. 'Off' Licences - authorising the sale of alcohol for consumption off the premises. Again, these licences may be for beer, cider and wines or beer, cider, wines and spirits. Off-licensed premises include supermarkets [5].

Drink driving and the legal alcohol limit

In 2013 between 220 and 260 people were killed in accidents in the UK where at least one driver was over the drink drive limit. There were an estimated 240 deaths.

These figures are too high but accidents involving drink driving have decreased hugely over the last 35 years. Deaths and serious injuries related to drink driving fell by more than three-quarters between 1979 and 2012 [37].

How alcohol affects driving

Many of the functions that we depend on to drive safely are affected when we drink alcohol -

  • The brain takes longer to receive messages from the eye,
  • Processing information becomes more difficult,
  • Instructions to the body's muscles are delayed resulting in slower reaction times [38].

You can also experience blurred and double vision, which affects your ability to see things clearly while you are driving. And you're more likely to take potentially dangerous risks because you can act on urges you normally repress [38].

How would I be tested for drink driving?

Even small amounts of alcohol affect your ability to drive and the only safe advice is to avoid any alcohol if you are driving.

If the police want to investigate whether you are over the drink driving limit, they will carry out a screening breath test at the roadside. To do this, they will use a breathalyser.

If you fail this test, or if they have other grounds to believe that your driving was impaired through drink, you'll be taken to a police station and given a final breath test. At the station you will need to provide two more breath specimens into a complex breathalyser.

The lower of the two readings is used to decide whether you are above the drink driving limit.

If the evidential breath sample is up to 40% over the limit you have the right to replace your breath specimen with blood or urine - the police officer will decide which test you will have. If your evidential samples show that you are over the limit, you will be charged.

The police can carry out a breathalyser test if you have committed a moving traffic offence (such as banned turns or going through a red light) been involved in an accident, or have given the police grounds to believe you are over the limit.

The police are allowed to stop any vehicle at their discretion, and will often set up drink driving check points over periods such as Christmas and New Year's Eve [35].

What's the punishment if I get caught drink driving?

Anyone caught over the legal alcohol limit when driving will be banned from driving for at least 12 months, and fined up to £5,000. You can also be given between three to 11 penalty driving points. And you could be sent to prison for up to six months. Imprisonment, the period of disqualification, size of fine and penalty points depend on the seriousness of the offence [39]. If you're caught drink driving more than once in a 10 year period, you'll be banned for at least three years [35].

How much can I drink and stay under the limit?

There is no fool-proof way of drinking and staying under the limit. The amount of alcohol you would need to drink to be considered over the driving limit varies from person to person. It depends on [35] -

  • Your weight, age, sex and metabolism,
  • The type and amount of alcohol you're drinking,
  • What you've eaten recently,
  • Your stress levels at the time [35].

Even small amounts of alcohol can affect your ability to drive so the only safe advice is to avoid any alcohol if you are driving [35].

How to ensure you don't drink and drive

  • Arrange within your group of friends who's going to be the designated driver. A designated driver is the person who abstains from alcohol on a night out so they can drive the rest of their group of friends home safely.
  • If you live somewhere with good public transport links - take advantage of them. If you're planning on staying out beyond the last train, tube or bus, make sure you've got a couple of taxi numbers.
  • If you have no option but to drive, stick to zero alcohol beers, mocktails or standard soft drinks.
  • Not every night out has to involve a bar or pub - book a table at a restaurant or try an alcohol-free night on the town [35].

Mixing with other drugs

Combining drugs usually increases the risks. As well as killing people on its own, a very significant proportion of deaths from drug poisoning are caused by alcohol taken in combination with other drugs.

Alcohol is a depressant and when taken with other drugs which have depressant properties the effect is multiplied. This makes it more likely for someone to pass out and choke on their own vomit or stop breathing. Drugs that can have this effect include the opiates, (such as heroin and methadone), benzodiazepines, (such as 'Valium' / diazepam or temazepam), and dissociatives (such as ketamine and DXM). A dose of these drugs which you have taken before without problems could be fatal in combination with alcohol.

Alcohol addiction and tobacco addiction are tightly associated, with high proportions of people dependent on one substance also being dependent on the other. Alcohol seems to make people enjoy smoking more, and a common trajectory of addiction is people progressing from only smoking when socialising and drinking to smoking all the time. The chance of mouth cancers is also much higher in people who smoke and drink together, compared to people who use one but not the other drug. Care should be taken not to chain-smoke when drinking.

Many medical drugs have side-effects when taken with alcohol. Others may not work effectively. Always read the leaflet or check with your doctor [1].

Mixing alcohol with other drugs can drastically increase the damaging effects of drinking. For example, combining alcohol with narcotics (i.e., heroin, OxyContin®, methadone) can cause slowed breathing, heart attack, and death. For some, even the combination of alcohol and aspirin can be extremely dangerous [16].

  • Alcohol + cannabis - nausea, vomiting, panic, anxiety and paranoia.
  • Alcohol + energy drinks (with caffeine), ice, speed or ecstasy - more risky behaviour, body under great stress, overdose more likely.
  • Alcohol + GHB or benzodiazepines - decreased heart rate, overdose more likely [1], [40].

Paraphernalia

Pumps, bottles, glasses [5].

Detox

The physical dependency carried by an alcoholic is overwhelming. Often when trying to stop drinking alcohol you will experiences withdrawal symptoms and cravings that overwhelm you, sending you right back to the bottle as a way to find comfort. Going at it alone or cold turkey is often unsuccessful. If you are committed to getting sober then entering into a treatment facility will aid you through alcohol detoxification, getting you through the painful withdrawal and preparing you for relapse prevention treatment [41].

What is alcohol detoxification?

Alcohol detoxification is the process in which your body will be cleansed of the chemicals and toxins related to alcohol abuse. It takes place in a rehab facility or hospital setting to offer you a secure environment that is free of temptations. You will be withdrawing from alcohol which can be painful and overwhelming. Doctors and staff will be there to support you and give you the care you need to detox as comfortably as possible [41].

Medical detox

Medical detox takes the typically detoxification process and allows your to receive a prescription medication, typically a benzodiazepine medication, to reduce symptoms of withdrawal and control cravings. Once you have passed the withdrawal period your medication will be weaned so that you do not develop a secondary addiction. Cravings for alcohol often linger, a prescription medication can be given throughout the remainder of your treatment to lessen cravings, some which even will make you physically ill when drinking alcohol [41].

Rapid detox

For those with more severe alcohol abuse problems that can pose a health risk a rapid detox may be the best option. This treatment takes place in a hospital setting with 24/7 medical monitoring. Your doctor will put you into a medically induced coma then intravenously administer medications to quickly detox your body. You will be woken up from this procedure past the withdrawal period and ready to continue onto other areas of treatment [41].

Outpatient

Those with mild to moderate alcohol addictions may be able to recover in the comfort of their own home through an outpatient treatment program that offers pharmaceutical treatment for alcohol. The individual will receive and benzodiazepine medication to ease symptom of withdrawal, allowing them to detox safely and more comfortably. The individual will be weaned from this medication and then placed onto a medication that will help control and cravings for alcohol such as; Disulfiram, Naltrexone and Acamprosate, all of which work in similar ways to prevent relapse. The individual will return to the outpatient treatment facility dor regular assessments and medication adjustments as well as therapy and counseling. The addiction to alcohol is not purely physical making therapy and counseling just as important for the recovery process and to prevent relapse [15].

Inpatient

Severe alcoholics require an inpatient treatment program where they will receive 24-7 medical care. The treatment process is similar to that of the outpatient treatment with the major exception being the patient is recovering in a controlled environment with medical care that will ensure their health an safety during the treatment process. Under direct supervision of a medical doctor the patient will go through detox where they will work through the withdrawal period with a benzodiazepine medication to relieve any pain or discomfort. Upon completion of the detox process the patient will continue on with various counseling and therapy sessions that are tailored to their individual recovery needs [15].

Units of alcohol

A unit is a way of expressing the actual amount of pure alcohol that is in a drink. This allows you to compare how strong one type of alcoholic drink is to another type [2]. For example -

  • half a pint of lower-strength beer, lager or cider (ABV 3.6%), or a 25ml measure of spirits (ABV 40%) is 1 unit,
  • one pint of stronger beer (ABV 5%) can be almost 3 units, and
  • one large glass (250mls) of mid-strength wine (ABV 12-13%) can be over three units [2].

Check the label on drinks as they often show the number of alcohol units. If they don't, you can calculate the units by multiplying its ABV, by the volume of the drink (in mls) and then dividing by 1,000 [2].

What is a unit?

  • one pint of normal strength lager (3% - 3.5%) is equivalent to 2 units,
  • one 275ml bottle of alcopop (5.5%) is 1.5 units,
  • a 175ml glass of 12% wine is 2 units,
  • a single measure of spirits (40%) is 1 unit [6].

These are measures of alcohol as might be bought in a restaurant or pub. Many drinks poured at home will be more generous and so contain more units of alcohol [6].

History

Alcohol is an extremely ancient element of human diet. As well as being a nutrient, it has functioned as a recreational drug, a euphoriant, a medicine, a ritual substance with symbolic and cultural significations, and so on. It played a strong role in Greco-Roman religion, where it was identified with the god Dionysus or Bacchus, and is still used in the Catholic Church as the Eucharist, symbolic of the blood of Christ and a link with the divine.

In pre-modern societies beer and wine were widely consumed; water was often impure and carried infections, while wine was a safe source of liquid. Beer tended to be the drink of the poor, and was in many ways a food as much as a drink, owing to its offering of cheap calories. Beer was consumed for breakfast in medieval and early modern Europe, mixed with oatmeal as a form of porridge. It was also drunk throughout the day; it is likely that many individuals went through life in permanent state of semi-drunkenness; when they drank to get drunk at festivals and celebrations, they tended to get 'dead drunk' and did not stop until unconsciousness intervened.

While distillation had been practiced for centuries, the modern age brought new techniques, with improved copper stills and the availability of sugar assisting the process. Aqua Vitae or spirits were much stronger than the traditional beers and wines - they had a higher ethanol content and could be kept for long periods without deterioration. Their use spread rapidly, resulting in the scenes of drunken excess depicted by Hogarth in the 'Gin Lane' prints. Whiskey and brandy improved with age, and brandy was added to wines to produce 'fortified' wines. Slave-produced sugar from Britain's West Indian colonies was used to produce rum.

Unlike Western drinks, which have typically been brewed from fruit and grain starches, Far Eastern alcoholic beverages are traditionally fermented from sugars and grains such as rice. Culturally, they have been consumed with food rather than on their own, although recent decades have seen a rise in drinking and socialising subcultures, particularly among young people [3].

Making and drinking alcohol goes back many thousands of years to the earliest days of civilisation. This probably first happened in the Middle East where grapes grow wild without cultivation. Alcohol is mentioned in the Old Testament when Noah plants a vine yard after the Flood and becomes drunk. The 'evils of getting drunk' are recorded on Egyptian papyrus from 3500BC. The population of ancient Greece was noted for heavy drinking. In ancient Rome getting drunk was almost a national pastime but it was an offence to be drunk in charge of a chariot.

Many societies and religions have allowed the use of alcohol. The Roman Catholic and Jewish religions include wine in their ceremonies. However, the Islamic faith (Muslims) and some Christian groups such as the Mormons do not allow its use.

For centuries 'ale houses' and beer drinking have been a part of everyday life in Britain. Because of the lack of pure drinking water, beer was commonly the main drink to have with a meal.

In the 15th century there was concern that ale houses were meeting places for working class political radicals, and magistrates were given powers to close down houses that were seen as causing trouble.

In America, the Temperance movement had far more effect. In the early 20th century alcohol was banned in many southern states and in 1919 Prohibition was introduced, banning alcohol in all of America. However, because there was no widespread public support for Prohibition, it did not stop the manufacture or drinking of alcohol. Poor quality 'bootleg' alcohol was sold in illegal drinking clubs called 'speakeasies'. These were run by gangsters such as Al Capone, and crime and violence flourished. Eventually in 1933 the law which banned alcohol in America was repealed. By then gangs (including the Mafia) had learnt how to make and sell illegal alcohol. Many then switched to drug dealing.

Alcohol is now a major source of government revenue in the UK. In 1999 the tax on a 70cl bottle of spirits was £5.48, £1.12 on a small (75cl) bottle of wine and almost 25 pence on every pint of beer sold.

During the 1990's new alcoholic drinks seemed to be being targeted at young people. These included strong lagers and ciders and 'alcopops', high alcohol content drinks which do not taste of alcohol, such as lemonades. As well as possibly leading to more young people drinking at a younger age this may result in increased drunkeness, with more alcohol being consumed in a short space of time.

From 2010 to the present date there has been a resurgence in gin, with many flavoured varieties achieving popularity. The craft beer movement has also seen beer sales rise. Pubs continue to close down however, with CAMRA (Campaign for Real Ale) suggesting that 27 are closed in the UK every week [6].

The history of alcohol stretches back thousands of years. As the the prototypical depressant, it was intentionally produced and consumed by humans as early as 10,000 B.C., as established by the discovery of beer jugs from the late Stone Age. Further evidence shows it continued to be used throughout ancient societies around the world.

The first records of distilled alcohol was from Greek society during the 1st century during research into medical and alchemical uses. Later, between the 12th and 14th centuries, distilled alcoholic beverages were distributed throughout Europe and were used widely.

In medieval Europe, the consumption of alcohol was used as a way of avoiding water-borne diseases such as cholera. This was because the process of boiling water and fermentation with yeast involved in the production of alcohol killed dangerous bacteria.

Alcohol became only used more widely as history progressed, its use sanctioned by church establishments. When America was established, a heavy drinking culture became established with it - communal binges occurring at public events during which participants would drink heavily until intoxicated.

Today, alcohol is the most widely used recreational drug worldwide; advertised by large companies which produce and sell alcohol on a mass scale [18].


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