It is easier for thin people to get drunk



"He drank seven mugs of beer. It made him relaxed and cheerful, he became happy and his face smiled." The reveler was Enkidu, friend and companion of the Sumerian king Gilgamesh - according to the ancient oriental epic.

Alcoholic beverages have been made by humans since ancient times. They discovered the stimulating, disinhibiting and intoxicating effects of fermented fruits or cereals thousands of years ago. The use of alcohol has been ritualized many times - including wine as an altar sacrament in Christianity. In many cultural circles, exhilarating drinks are also socially established as luxury goods. Even today we consider an occasional swipe to be normal. We often endure intoxication with a sense of humor.

In many cultures, alcohol was and is a matter of course part of everyday food. In earlier centuries, consumption also had a hygienic justification: water was often unclean. In addition, this was a form of preserving easily perishable dishes ("Kleine Kulturgeschichte des Alcohol", Spektrum der Wissenschaft 8/98, p. 62).

Today we can meet such demands differently. Still, people in many western countries consume alcoholic beverages in large quantities. With over ten liters of pure alcohol per inhabitant per year, Germans are among the international leaders. That corresponds to 134 liters of beer and other beverages per capita, and this number is still deceptive: In Switzerland, 7 percent of fifteen to seventy-five year olds consume half of all alcoholic beverages. A total of 50 percent of this age group drink more than 95 percent of the drug. Similar figures are likely to apply to the other western countries.

Most of the time, the health impairment caused by alcohol consumption is played down. It is well known that the drug can be addictive because of its effects on the psyche. But it is often underestimated how many people have already reached an early stage of alcoholism. Most people know that alcohol attacks the liver, brain and other organs. But they don't care much about it in everyday life. Many are also not even aware that the daily glass of wine or beer can damage individual organs and increase the risk of cancer. On the other hand, we value the mood-enhancing effect in good company.

Ambivalence shapes the alcohol aura: One-sided advertising still supports the carefree use of alcohol. Many of the reports that have been widespread in recent years that red wine would protect against heart and circulatory diseases are only partially true. Often the data are not based on solid scientific research, but are poorly verified secondary results of other studies. Fatal effects of alcohol, which can occur at the same time, are all too often concealed.

It is particularly irresponsible to recommend such drinks to others without consulting a doctor in order to support their health. Under certain conditions, one "drink" a day actually seems to counteract arteriosclerosis and thus heart attacks and strokes. But it has now also been shown that other organ systems suffer from consumption, even if only small amounts are involved.

Our usual attitude towards alcohol has long been a social problem. This applies not only to the considerable cost of illness, but also to the far-reaching social impact. The frivolous handling promotes abuse up to and including drunkenness. Because not everyone knows how to handle intoxicating drinks in a socially responsible and responsible manner. Apparently, some people are more susceptible to alcohol abuse or to morbid alcoholism than others.

Alcoholism has been considered a disease since 1968. Strictly speaking, this does not yet include purely psychological alcohol addiction. According to today's medical opinion, only those who show the typical physical withdrawal symptoms during abstinence are alcoholics. The typical and most important symptom of psychological dependence is the "loss of control": once he has started drinking, the patient cannot stop drinking. Once the addiction has developed, it appears to persist - even after years of abstinence: Even the "dry" alcoholic remains ill for life. In addition, there is a strong, often indomitable craving for alcohol as a characteristic of psychological dependence. The physical dependence manifests itself on the one hand in the fact that the person concerned seems to "tolerate" more and more alcohol at the beginning and also needs more and more to achieve the same pleasant effect. On the other hand, without the drug, he suffers withdrawal symptoms such as tremors, sweating, heart racing, and inner restlessness.

According to estimates by the German headquarters against the dangers of addiction, around two and a half million alcoholics in need of treatment live here in the country. Around forty thousand people die each year in the Federal Republic of Germany as a result of excessive drinking, seventeen thousand of them from cirrhosis of the liver. More than 2,200 alcoholic children are born here every year. And probably 250,000 children, adolescents and young adults under the age of twenty-five are at high risk of alcohol or are already dependent.

Cost of alcoholism

The total economic costs of alcohol abuse and addiction in Germany amount to 30 to 80 billion DM annually, including the burdens on the health system, the loss of productivity and the consequential costs of alcohol-related traffic accidents and criminal offenses. In contrast, the state currently collects more than seven billion marks in alcohol taxes. And the German alcohol industry has had a steady turnover of between 30 and 35 billion marks for some time and employs around 85,000 people.

Clinicians estimate that up to three quarters of alcoholics who come for inpatient withdrawal treatment also suffer from other specific organic sequelae of alcohol consumption. Liver damage is only a part of it. Also of the patients under 65 who see a general doctor, around one in ten is involved in chronic alcohol abuse - as is around one in five of those who are hospitalized. There is hardly an organ that cannot be damaged as a result of chronic alcohol consumption. It is therefore important that resident doctors and clinicians expect alcohol-related diseases, recognize them and, if necessary, also address the connection. However, doctors differentiate between temporary ("acute") and permanent ("chronic") organ damage.

The alcohol contained in the drinks itself only directly causes part of the reactions. Some of its breakdown products are also poisonous. And other ingredients in alcoholic beverages also affect organs. Some are only converted into toxic or carcinogenic substances in the body.

As an example, we would like to describe some of the most common physical injuries caused by alcohol consumption. As far as we know today, the alcohol itself is not a carcinogen, i.e. it is not directly cancerous for the cells, but a poison for the tissues.

Even small amounts of the chemical compound "ethanol" - the fermentation product contained in the drinks (technically also called ethyl alcohol) - directly attack the mucous membrane cells of the oral cavity, esophagus and stomach. Many cells become inflamed or even die. Doctors speak of "erosion". If you drink several schnapps, this causes acute inflammation, especially in the lower esophagus, which increases the damage due to the activation of immune reactions. In addition, higher blood alcohol levels inhibit the regular muscle contractions of the esophagus, which carry its contents to the stomach. The sphincter at the bottom of the esophagus also relaxes. Stomach acid or the acidic stomach contents then easily get into the esophagus and even into the mouth and irritate the inflamed mucous membranes even more. The patient experiences heartburn, acid regurgitation and painful difficulty swallowing. In serious cases, the inflamed esophagus becomes so narrow that surgery is necessary. The slack muscles are also the reason why sleeping drunks can choke on vomit.

The Canadian doctor William Beaumont described damage to the gastric mucosa caused by alcohol as early as 1833, when he was treating a patient with an abdominal wound into whose stomach he could see. If this man had drunk a lot of alcohol, the mucous membrane would become red and inflamed shortly afterwards, forming a cloudy mucus.

Today we know that especially high-percentage beverages such as whiskey and cognac, but also beer and wine, irritate and swell the stomach lining. They cause acute inflammation, hemorrhage and exfoliation of cells, whereby cells die directly. Sometimes a bloody alcoholic gastric mucosal inflammation occurs, an "acute erosive gastritis". The patient usually does not notice this because he does not feel any pain. However, pure alcohol diluted with water is often more devastating than some alcoholic beverages with a comparable alcohol content. These drinks, such as red wine, apparently contain "protective substances" that "buffer" the irritants.

The mechanism by which alcoholic beverages act as an aperitif ("appetizer") and digestif ("digestive aid") and make a voluminous meal easier to digest is largely unknown. Certain signal substances may be released, which also activate digestion via the brain. The alcohol itself stimulates gastric acid production, if at all, only in low concentrations of up to five percent by volume. High-proof alcoholic beverages from around twenty percent by volume even inhibit acid production. As we recently demonstrated using the example of beer, on the other hand, certain by-products of the fermentation process have a stimulating effect: namely succinic acid and maleic acid. Distilled drinks practically do not promote gastric acid secretion.

The lining of the small intestine is also affected by alcohol. Acute redness, cell exfoliation and minor bleeding occur. As in the stomach, the alcohol has a direct toxic effect on the cells on the one hand, and on the other it triggers an inflammatory process that hinders blood flow to the small intestine. This also temporarily disrupts the active absorption of nutrients through the intestinal wall.

Most of these acute changes after drinking alcohol will soon resolve. However, it takes more than 24 hours, for example, for bloody damage to the gastric mucosa to heal after consuming a sharp drink. It is evident that the continued erosions that occur with regular alcohol consumption can cause long-term chronic damage.

The extent to which many different pathological processes are intertwined can easily be described using the example of the small intestine. With constant inflammation, the surface of this section of the intestine shrinks. This has been shown in men who consume more than 60 grams of alcohol per day and in women who consume more than 30 to 40 grams per day. The ethanol is likely to inhibit normal, regular cell renewal. As a result, the organism soon suffers from a lack of nutrients. In particular, glucose - the most important source of energy - and amino acids, from which proteins are built, are no longer given to the body in the necessary quantities. Such patients lose weight. And they suffer from diarrhea. Because as a result of malnutrition, the water and electrolyte balance no longer works well. In addition, bacteria proliferate in the disturbed environment that normally do not exist in the small intestine. If, at the same time, the pancreas is chronically inflamed, which often happens with alcohol abuse, and it therefore does not supply enough digestive enzymes, the food cannot be sufficiently broken down due to the lack of enzymes.

The liver diseases that are common with chronic alcohol abuse and many other typical organ damage are likely to be largely due to digestive disorders in the small intestine. In the upper small intestine, fatally more harmful substances get into the blood and lymph through the damaged mucous membrane. These include very large molecules that should have been broken down beforehand, as well as so-called endotoxins, bacterial poisons. Immune cells react to the "blood poisoning". They release inflammatory substances throughout the body, cytokines and interleukins, which also affect the liver and pancreas. How this works in detail, however, is still the subject of research.

Regular alcohol consumption significantly increases the risk of many types of cancer. The more someone drinks, the higher it gets. Ethanol itself does not have a direct carcinogenic effect. However, cells previously damaged by alcohol are particularly vulnerable to carcinogens. We take these in with food, or they arise in the liver from precursors. Alcoholic beverages also contain such substances. A healthy liver can largely defuse carcinogens and toxins. But under the influence of alcohol it is much less able to do this, especially since the alcohol itself reduces these functions: The liver always breaks down alcohol preferentially. The cancer-causing compounds accumulate in the blood and have long contact with the inflamed and therefore particularly vulnerable mucous membranes - a vicious circle.

Even if the amounts are not very large, the risk increases that malignant tumors, so-called carcinomas, form in the mucous membrane of the oral cavity, larynx, throat and esophagus. The amount of alcohol is decisive here; the type of drink does not seem to matter much. According to a new Heidelberg study, the risk of developing oral cavity or larynx cancer increases by more than thirteen times with 75 to 100 grams of alcohol per day, i.e. three to four large beers or a bottle of wine. If someone also smokes, the risk becomes significantly higher. Although alcohol can cause acute gastritis, according to current knowledge, frequent alcohol abuse does not increase the risk of chronic gastric mucosal inflammation, gastric or duodenal ulcer or gastric cancer.

Erosion with consequential damage

But the risk of rectal cancer increases with alcohol consumption, and most likely that of colon cancer as well. Benign colon polyps form two to three times as often as usual. Anyone who drinks more than a liter of beer a day is three times more likely to get rectal cancer. Several processes are likely to be responsible for this. On the one hand, the alcohol in the blood itself damages the mucous membrane cells of the rectum. In addition, its poisonous breakdown product acetaldehyde maltreats the genetic material of the cells. Apparently, bacteria living in the rectum "digest" alcohol, which diffuses from the blood into the rectum, into the poisonous acetaldehyde. And there, too, the carcinogenic ingredients of the drinks, which also reach the rectum in the blood, become effective. In this case, it is particularly easy for you because, with constant consumption, ethanol ensures that these mucous membrane cells divide unusually often. However, this makes them particularly sensitive to toxic and cancer-causing substances.

The alcohol-related diseases of the liver, the most important detoxification organ, which also has to dispose of the majority of the ethanol and are therefore heavily burdened, are well known. The incidence of fatty liver, liver fibrosis and liver cirrhosis correlates closely with daily alcohol consumption. The risk increases significantly for men from 40 to 60 grams of alcohol per day, for women from 20 to 30 grams. Fatty liver can develop after a short period of abuse, liver fibrosis or cirrhosis after several years of alcohol abuse. It is from 60 grams per day in men increased six times, from 80 grams fourteen times. Women have a higher risk of cirrhosis of the liver with just 12 grams of alcohol per day or a glass of beer.

On the one hand, ethanol and its toxic breakdown product acetaldehyde damage the liver cells themselves. The most important causes of alcohol-induced liver disease are probably also immune reactions caused by alcohol. Components of intestinal bacteria (endotoxins) and certain messenger substances (interleukins and cytokines) seem to cause chronic inflammation in the various organs, which ultimately causes organ damage. There are also genetic requirements.

If the liver is already inflamed, such as chronic hepatitis, alcohol accelerates its course. This applies in particular to hepatitis C infection, which often leads to cirrhosis and later liver cancer. The hepatitis C virus multiplies significantly faster with more than ten grams of alcohol per day. Patients have to refrain from alcohol altogether. If the hepatitis B infection has healed without permanent tissue damage, you don't have to be so careful. In Germany alone, around 1.4 million people currently have chronic hepatitis, of which around 600,000 have hepatitis C ("Hepatitis C: The silent people's disease", Spektrum der Wissenschaft 3/2000, p. 28). The rate of new infections every year is 15,000.

What is less well known is that the pancreas often cannot withstand alcohol consumption in the long term. Anyone who consumes more than 80 grams of ethanol a day, which corresponds to about one liter of wine, is at high risk of "chronic alcoholic pancreatic disease" or "pancreatitis". This manifests itself in attacks with severe abdominal pain. The gland then produces insufficient digestive enzymes and too little of the blood sugar hormone insulin, which also explains why alcohol abuse often leads to diabetes. Mainly middle-aged men are affected by alcohol-related pancreatitis. With them, the disease manifests itself clinically after an average of seventeen years, in women after ten years of drinking pleasure. Obviously, it is not the type of drink that is decisive, but the absolute daily amount of alcohol. Twenty grams a day are considered a risk dose, but even less does not seem to be safe with certainty. A lower threshold dose cannot be demonstrated.

Why does the pancreas become inflamed? It is possible that the secretion is too thick because the alcohol causes the release of water and bicarbonate to decrease, but that of the proteins (digestive enzymes) is increased and the concentration of calcium in the secretion also increases. Calcium crystals and protein deposits are now formed. As a result, the small ducts in the pancreas would become calcified and clogged over time. Enzymes could also pass from the ducts into the surrounding glandular tissue, because alcohol makes their walls more permeable. The consequences: inflammation, self-digestion of parts of the organ and conversion of the glandular tissue into connective tissue. The latter, called "fibrosis", can ultimately affect the entire pancreas. Recent findings also suggest that alcohol directly damages the cells that produce digestive enzymes.

Chronic pancreatitis means an increased risk of pancreatic cancer. The alcohol does not directly trigger the cancer itself, but promotes it indirectly because of the inflammation.

It is said again and again that alcoholic drinks in moderation are good for the heart and blood vessels. But they can also be very damaging to the cardiovascular system. Low to moderate consumption has been shown to reduce the risk of heart attacks and strokes somewhat. But this only applies to a limited extent. Thanks to regular alcohol consumption, only those cerebral infarctions that occur because of arteriosclerotic vasoconstriction seem to be less common. Strokes caused by vascular bleeding ("bursting veins") do not decrease. Also, only up to fourteen grams of ethanol per day have a protective effect. From forty grams, the risk of stroke even increases. And occasional binge drinking generally increases the risk, even if the person otherwise drinks little.


Risk to heart and blood pressure

The risk of coronary heart disease and, ultimately, heart attack, on the other hand, seems to be reduced by alcohol if someone drinks a lot. The effect is independent of the type of drink, so it doesn't just apply to red wine. Alcohol makes blood lipids more favorable and less unfavorable (i.e. cholesterol). The doctors suspect that alcohol makes the blood "smoother", therefore less vascular calcification occurs and the blood does not clot as quickly. The effect is similar to that of aspirin, which patients with heart disease receive to "thin the blood". It is also of a similar order of magnitude: it lowers the risk by about a third. Phenolic ingredients also seem to have a protective effect, especially in red wine. The phenols also lower blood pressure because they widen the blood vessels.

In the long run, however, the heart cannot cope with heavy alcohol consumption. Ethanol is toxic to the heart muscle cells. Chronic abuse puts such a strain on the organ that it expands and a cardiac insufficiency that requires treatment arises. Cardiac arrhythmias are also common.

Patients with high blood pressure - hypertensive patients - should avoid alcohol if possible, because the drug increases blood pressure. Often the values ​​improve when someone drinks less. Men who drink 30 grams or more of alcohol per day, women 20 grams or more, have measurably high blood pressure.

With every excess of alcohol, millions of brain cells perish directly from the poisoning. Apparently they will not be replaced. As a result, an alcoholic's brain loses mass noticeably over the years. The brain functions also suffer from this. In addition, there is damage to other parts of the central and peripheral nervous system. Doctors then diagnose characteristic neurological disorders. They range from loss of perception and memory loss to disorders of movement coordination to excessive pressure sensitivity, muscle paralysis and numb areas of the skin.

It is tragic and frightening that expectant mothers can cause lasting serious harm to the unborn child with alcohol. The drug quickly reaches the same concentration in the child's blood as in the mother's. The child's organism has hardly any detoxification mechanisms and is therefore completely exposed to toxins. The toxic substances damage cells and hinder various growth and differentiation processes. The newborns are often underweight and grow worse than healthy children later on. They often show malformations on the skeleton and various organs, such as the heart, kidneys or genitals. A brain skull that is too small, eye defects and conspicuous facial features are also typical. Often these children are more or less severely mentally handicapped. The danger from alcohol to the child is greatest in the early stages of pregnancy, because then its organs, including the brain, develop and the cells have to divide particularly often and develop in a certain direction. Unfortunately, however, women usually do not have an aversion to alcohol after conception.

Most of the physical malformations in newborns are caused by alcohol itself and its breakdown products, especially the toxic acetaldehyde. Every three hundredth newborn is affected. Lighter brain damage and complex brain dysfunction are even more common. Apart from hereditary defects, alcohol is one of the most important causes of mental development disorders.

Obviously, the amount of alcohol consumed by the mother is not a measure of whether and how serious the damage to the child is. According to previous findings, there is also no harmless lower limit value. However, it has been proven that if the pregnant woman drinks 29 grams of alcohol per day, this irreversibly reduces the child's intelligence by an average of seven IQ points. Only the initial hyperactivity disappears over time. Almost every second affected child can only attend one special school; none reach secondary school entrance qualification, and only a few get into a more qualified occupation. Only about every ninth person can later live independently and start a family.

Fatally, around a third of these young people later become addicted to alcohol or other drugs. Because in the embryo and fetus, ethanol and its breakdown product acetaldehyde promote a later disposition to addiction.

Enjoyment with a downside

Why is alcohol so popular despite the harm it causes? Why is it even more and more consumed in the western world? The background is not entirely clear. But many factors are likely to work together here. It certainly plays a role in the fact that alcohol calms you down, brightens your mood, dampens stress, and relieves anxiety. According to surveys, people who drink one or two glasses almost every day feel more satisfied and subjectively healthier than people who largely avoid alcohol. The former are apparently also less prone to depressive moods than the latter, incidentally also less than heavy drinkers. In older people, alcohol is said to temporarily improve mental performance.

Medically speaking, moderate drinking would mean consuming a non-harmful amount of alcohol. From a medical point of view, the threshold to abuse is very different from one individual to the next and therefore cannot be determined, which is why general recommendations are prohibited. In addition, the individual cultures understand very different things by moderate drinking. That varies between 3 and more than 150 grams, as much as in two liters of wine. This amount is sure to damage the heart and circulation. Even in this country, the figures for lower limit values ​​vary considerably, between 17 and 40 grams per day for men and 12 to 20 grams for women. More recent epidemiological studies show that the risk of disease increases above these lower limit values.

How the body reacts directly to alcohol consumption does not only depend on the amount of alcohol in individual cases. Apart from other diseases, previous experience with the drug and the pharmacological tolerance of the person concerned also have an effect - which is individually different and initially increases with regular consumption. Mood and surroundings are also important. Stress reduction does not work equally well for all people. This effect of alcoholic beverages can apparently be used particularly effectively by those people whose families have always handled spirits in a controlled manner. People who drink moderately, but almost daily, seem to be able to cope better with stressful life events and to be more satisfied with their self-assessment of their health than abstainers or uncontrolled drinkers. Such beneficial effects still require confirmation.

On the other hand, there are well-documented undesirable psychological effects of moderate alcohol consumption. With long-term moderate consumption, at least for men, there is a risk that depression will set in over time. In the case of excessive consumption, this applies to both sexes.

However, individual consumption is also related to the socio-cultural background, environmental influences and behavioral norms - including incentives and opportunities to purchase alcohol. The family and professional situation has a great influence. And last but not least, genetic predisposition and metabolic status play a role in how someone reacts physiologically and psychologically, momentarily and in the long term, to alcohol and how easily they develop an addiction. Family, twin, and adoption studies clearly show a genetic predisposition to alcoholism. There is also evidence that genetic factors play a role in the development of individual drinking patterns. Men who abuse alcohol are mainly exposed to the environmental influences of childhood and adolescence. The consumption profile of women, on the other hand, is initially mainly genetically regulated, only with increasing age is more and more regulated by environmental conditions.

Alcohol addiction usually develops gradually. The line is usually difficult to draw - but it is estimated that one in seven people who regularly drink alcohol is already in the early stages of addiction. This also illuminates the responsibility of those around you who encourage people to drink at work or in cozy company. But those affected themselves and those around them usually deny the first warning signs.

A fine line to be addicted

Doctors differentiate between four phases in the development of alcohol addiction: It starts with the frequent drink in between to stimulate, calm or relieve. It becomes more worrying when someone drinks secretly, stocks up alcohol, or often has gaps in memory due to too much drinking. The "critical phase" has occurred when a person can no longer limit consumption, even when he tries in vain to stop drinking completely. Often he can no longer cope with his work well. His interests narrow down more and more, he only thinks about the next drink. Finally, in the "chronic phase", the patient becomes more and more weak physically. He is often drunk, sometimes for days, and "tolerates" alcohol less and less because the liver is already badly damaged. He also suffers from severe physical damage, up to delirium with clouding of consciousness, hallucinations and delusions. Severe alcohol addicts are also prone to other mental illnesses, such as depression and anxiety. Often there is an increased risk of suicide.

But not everyone who consumes a lot of alcohol, i.e. who abuses it, is dependent, i. H. "addicted". A disposition probably also plays a role. Some people do not become physically dependent for years despite heavy use. According to the behavior and reaction patterns, medical professionals differentiate between several types of abuse. Forty years ago, the American doctor Elvin Morton Jellinek (1890–1963) distinguished five types of alcoholics:

- The alpha type "drowns" problems and conflicts with alcohol. These people are mentally dependent, but not physically. In principle, you could stop drinking at any time.

- The beta type, the "habitual drinker", already drinks so much and often that it can be physically harmful, but is not physically dependent, i. i.e., does not suffer from physical withdrawal symptoms during abstinence. These people drink regularly when they are thirsty.

- The gamma guy is addicted to alcohol, i. H. psychologically and physically dependent. If he does not drink alcohol for a long time, he will suffer physically. After the first sip, he continues to drink to the point of intoxication - he loses control over consumption.

- The Delta type is the "mirror drinker". He always "needs" a certain alcohol level. Otherwise, he will experience physical withdrawal symptoms.

- The Epsilon guy is the "quarter drinker" who gets drunk at intervals, then for days and until he is unconscious. It is psychologically dependent and, once started, cannot stop.

Not alcoholism per se, but actually abuse of any kind with its health, social and economic effects poses the greater problem for society. Drunkenness and drunkenness cause great economic losses through illness, incapacity for work, traffic accidents and criminal offenses, not to mention physical and emotional damage to the victims and their relatives. Around a third of the violent acts in the family take place under the influence of alcohol. The social environment of drinkers suffers in other ways as well. In the Federal Republic of Germany five to seven million people are likely to live in close association with an alcoholic.

Doctors now partially understand why some people become addicted and others not. The doctor Wilhelm Feuerlein, who worked at the Max Planck Institute for Psychiatry in Munich, used a model in 1998 to identify three major causal factor groups that can influence and reinforce each other - and which the person affected can no longer avoid on his own. According to this model, alcohol is, first of all, highly addictive. It changes nerve cell signals in the brain, especially in centers that control the handling of emotions. This is precisely what can trigger permanent shifts in the neuronal excitation pattern in some people. Secondly, there are specific physical and psychological characteristics of the consumer, which are genetically and historically shaped. Third, special features of the environment have an impact. They range from general socio-cultural and socio-economic influences to features of the individual small space, i.e. primarily family, work, quality of living and economic situation.

Addiction to wellbeing

"Craving for frequent drunkenness is a disease caused by the chemical nature of alcoholic beverages." This is what the Scottish doctor Thomas Trotter (1760-1832) said in 1788. What's happening in the brain?

Our brain apparently has a "system of wellbeing" that is closely linked to our motivations. Sometimes it is also called the "reward system". It helps us to seek behaviors that create wellbeing. This system is widely ramified and also has branches in the frontal areas of the brain. The mood enhancement through alcohol seems to come about because certain pathways are activated, which release "endorphins", endogenous opiates. (They got their name because morphine and other opiates can communicate with nerve cells in their place.)

This process can evidently "grind in". Repeated drug administration sensitizes the wellbeing system to the substance in question: it now reacts more strongly to the same amount of alcohol. Certain behavior patterns are also established. In addition, this system is activated later in the run-up to drug use. As an impetus, it is enough to drop by the local pub by chance or to meet a drinking buddy. Unpleasant memories also activate the system: They also motivate people to consume alcohol.

This system evidently rates alcohol withdrawal negatively. Withdrawal therefore creates a strong fear, which the addict tries to resolve with all possible means. Here, too, there seems to be a kind of learning effect: With repeated withdrawal, this fear reaction becomes stronger.

A wide variety of signal substances are linked to the wellbeing system. The messenger substance dopamine takes center stage.Because many of the molecular processes have already been thoroughly researched, chemical substances can now be developed to aid the alcoholic in his struggle for abstinence. In technical jargon, these alcohol cessation drugs are called "anti-craving drugs". Because they address the wellbeing system, they reduce withdrawal symptoms and make it easier for the patient to avoid relapse. These drugs also suppress cravings for the drug.

Only about every twentieth alcoholic succeeds in becoming abstinent without treatment. Technically supported weaning, on the other hand, is on average more successful than generally assumed. Whether withdrawal can be done on an outpatient basis or must be done in a clinic depends on the stage of the disease.

After the physical detox, which can take a few days to a few weeks, the actual psychological adjustment begins, which takes months. In the first few weeks in particular, patients are extremely at risk of relapse. Every therapy must aim to reduce the motivation to drink and to strengthen the desire to abstain. It is just as important that the patient sees his illness as such, understands the cause of his addiction and fundamentally rethinks his attitude towards alcohol, as is the development of specific defense mechanisms against drinking. The support from the social environment is of great importance. The fear of sanctions such as driving license withdrawal, separation from a partner or loss of a job also play a major role in this process.

The best prospects for withdrawal exist if the patient remains in psychotherapeutic treatment for at least several months after detoxification in a clinic. In severe cases, it is advisable to initially care for the patient in an appropriate facility for a period of time and then to continue providing outpatient support. Under these conditions, up to every second severely alcoholic person succeeds in renouncing alcohol in the long term.

In Germany, however, only about every hundredth alcohol addict experiences inpatient relapse prevention each year. That is only a small fraction of the two and a half percent of alcoholics who are detoxified once or several times a year. In both cases, but especially in follow-up treatment, there is a considerable deficit here in this country.

New treatment concepts are therefore urgently needed. Medical care must be close to the community, start immediately after hospital treatment and be able to be provided by the family doctor in cooperation with an addiction therapist. Doctors need special training for this. But the advanced training in addiction medicine is very bad. It is therefore to be welcomed that the first German chair for addiction research was established two years ago at the Mannheim Central Institute for Mental Health at Heidelberg University - a first step towards countering the deficit. The first holder of the chair, Karl Mann, demands that more dependent and less harmed alcoholics sufferers, in addition to outpatient care by their family doctor, should definitely take part in self-help groups such as Alcoholics Anonymous, Blue Cross members or Guttemplern. He also advocates checking with each patient whether drug support for abstinence is appropriate, at least for the first six months after withdrawal.

A number of alcohol cessation drugs that affect the brain's wellbeing system are available. According to clinical trials, acamprosate (Campral) and naltrexone (Nemexin) in particular appear to reduce withdrawal symptoms and reduce the risk of relapse. Several studies have shown that twice as many patients - over forty percent - stay abstinent in the first year after withdrawal when taking acamprosate than when they are given a dummy drug. The success persists even after the drug is discontinued.

The social and societal consequences of abuse are more in the public eye than the health risks of moderate consumption. Much research is still needed into the effects of moderate alcohol consumption. One thing is certain: Ethanol is much more harmful than previously thought. Just measuring mortality is not doing it justice. The impact of alcohol on disability is believed to be much more serious than its impact on mortality. According to a study by the World Health Organization, alcohol accounts for two percent of mortality, but three and a half percent of illnesses and more than six percent of the years of life "lost" by disability. This contrasts with the calculated three to four percent reduction in mortality, which must be interpreted with great caution, and which can be achieved through the effect of moderate alcohol consumption on the cardiovascular system. Our society thus has a serious problem of alcohol.

All in all, it is irresponsible to encourage people to enjoy alcoholic beverages or even to promote them without restriction. Because moderation is to be measured according to the values ​​at which disease-preventive effects are largely exhausted and disadvantageous consequences are unlikely. The doctor may recommend a glass every now and then - to those patients whose risk structure he knows well. There is no risk-free drinking of alcohol.

Bibliography


Alcohol and alcohol sequelae. Basics - Diagnostics - Therapy. By Manfred V. Singer and Stephan Teyssen (eds.). Springer, 1999.

Textbook of addictions. By M. Gastpar, K. Mann and H. Rommelspacher (eds.). Thieme, 1999.


Addresses


German headquarters against the risk of addiction (DHS), 59003 Hamm, PF 1369, Westring 2, Tel. 02381 / 9012-0

Austria: Central Office for Combating Alcoholism. A – 1150 Vienna, Hackengasse 13.

Switzerland: Swiss specialist agency for alcohol and other drug problems. CH-1003 Lausanne, Av. Ruchonnet 14. Tel .: 021/3212911


glossary


Alcoholism (alcoholism, alcohol addiction, alcoholism)

The alcoholic feels an insurmountable desire for alcohol or to continue drinking. The addiction arises gradually and usually increases over the years. Loss of control after starting to drink and chronic abuse are typical. The term "alcoholism" came up in the mid-19th century. The disease has been recognized as a chronic disease in Germany since 1968. If left untreated, alcoholism is often fatal.

Alcohol abuse

Alcohol consumption is so high that it causes physical, psychological and social damage. There is not always alcohol dependence at the same time.

Mental alcohol addiction

The desire for alcohol is invincible because of its euphoric, stress-relieving effect. Withdrawal creates restlessness, depressive moods, and fear.

Physical (physical) alcohol dependence

With abstinence, mild to very severe physical withdrawal symptoms occur, depending on the stage: in particular vegetative disorders, tremors, clammy hands, sweating, inner restlessness, rapid heartbeat, insomnia, high blood pressure, in very severe cases also convulsions, hallucinations and clouded consciousness.


Alcohol in metabolism


Alcohol is quickly and almost completely absorbed by the stomach and small intestine. Some of it is already broken down enzymatically in the mucous membranes of the stomach and intestines. Lungs, kidneys and skin account for up to a tenth, usually significantly less, of the total alcohol, unchanged. The liver cells decompose most of them.

In the liver, the enzyme "alcohol dehydrogenase" (ADH) converts ninety percent of it into the toxic acetaldehyde - this is detoxified by "aldehyde dehydrogenase"; A system called "MEOS" breaks down almost ten percent of the alcohol, the rest is broken down by the enzyme "catalase". As long as the liver does not become ill, chronic drinkers "tolerate" more because blood alcohol levels from one per mille stimulate the MEOS. This then forms a particularly large number of alcohol-degrading enzymes.

Women tolerate alcohol less than men because the enzyme ADH in the gastric mucosa is less active in them. In addition, everyone has different types of ADH. Because most Japanese people lack one of these isoenzymes, they tolerate alcohol more poorly than other populations.

The so-called flush reaction - reddening of the skin due to dilation of the blood vessels, drowsiness, headache, palpitations and nausea - is due to the lack of an isomeric form of aldehyde dehydrogenase. This affects every second Asian in the Pacific region and every tenth to twentieth European.


Increase in cancer risk

Just one "drink" (10 grams of alcohol) per day increases the risk of cancer by that much
Oral cavity 30%
Throat 30%
Larynx 30%
Esophagus 30%
Liver 20%
Mammary gland 10%
Colon 5%
Rectum 5%



Alcohol not a medicinal product


Alcoholic beverages are a natural part of life for many of us. But it would be completely wrong to "prescribe" your own daily glass of wine or beer for health reasons. Because alcohol is not a drug, but a poison. Even one-sided advertising cannot hide this. The effect of alcoholic beverages remains ambivalent, including that of wine, even if, for example, the wine industry advertises their consumption with catchy slogans such as: "The good news from healthy wine!" or: "The daily glass of wine protects the heart and circulation!"