This is Part 1 of a Two part Pilot Study. The Result, Part two, will appear in the November issue
Introduction This pilot study was conducted to examine whether alcoholics in long- term sobriety continue to suffer from alcohol-related illnesses even after twenty or more years of continuous sobriety. Little has been written about the health outcomes of recovered alcoholics many years after they stopped drinking, particularly as it relates to academic research. Anecdotally, it has long been thought that once an alcoholic becomes abstinent that he will recover from his physical ailments brought on by the disease if he has not abused his body to having cirrhosis of the liver, chronic pancreatitis, or Korsakoff’s Syndrome to his brain, among other ailments. In recent years there has been some evidence that alcoholics may develop symptoms from previously undiscovered and/or dormant ailments which suddenly appear more than twenty years after their last drink. This study aims to ascertain whether the subject matter warrants a more in-depth investigation through a dissertation. Therefore, the primary question for this study is: “Do alcoholics with long-term sobriety continue to be afflicted with alcohol-related ailments more than twenty years after their last drink?” A secondary question is “what should the direction of future research be?”
Addiction, drug or alcohol – Repeated use of a psychoactive substance or substances, to the extent that the user, or addict, is periodically or chronically intoxicated, shows a compulsion to take the preferred substance (or substances), has great difficulty in voluntarily ceasing or modifying the substance used, and exhibits determination to obtain psychoactive substances by almost any means. Tolerance is prominent and a withdrawal syndrome frequently occurs when substance use is interrupted (World Health Organization (WHO), 1994). Addiction is often chronic with relapse always a possibility, even after years of sobriety or abstinence. There are various areas that can be affected by addiction, but for this study it will relate primarily to alcohol.
Alcoholism – E. M. Jellinek, a physiologist and researcher, who consulted with the World Health Organization and the American Medical Association in the establishment of alcoholism as a disease, defines it as “the use of any alcoholic beverages that causes any damage to the individual, society, or both” (Jellinek, 1960). In 1992, to establish a more precise and current definition of the term alcoholism, a 23-member multidisciplinary committee of the National Council on Alcoholism and Drug Dependence and the American Society of Addiction Medicine conducted a two year study of the definition of alcoholism. The goal of the committee was to create a revised definition that is scientifically valid, clinically useful, and understandable to the general public. Therefore, the committee agreed to define alcoholism as a primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. The disease is often progressive and fatal. It is characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking, especially the phenomenon of denial. The symptoms may be continuous or periodic (Morse & Flavin, 1992).
Abstinence – Refraining from drinking alcoholic beverages, whether as a matter of principle or for other reasons. The term “current abstainer”, often used in population surveys, is usually defined as a person who has not drunk an alcoholic beverage in the preceding 12 months; this definition does not necessarily coincide with a respondent’s self- description as an abstainer (WHO, 1994). Also, the absence of use of mood altering drugs or alcohol excluding caffeine, nicotine, and those that are prescribed by a physician for a legitimate physical or psychological complaint. For this study abstinence and sobriety will be used synonymously.
Long-term sobriety – For this study long-term sobriety will mean the abstinence from drinking alcohol or using any other mind-altering drug for twenty consecutive years or more.
Relapse – A return to drinking or other drug use after a period of abstinence, often accompanied by reinstatement of dependence symptoms (WHO, 1994). Also, the return of signs and symptoms of a disease after a patient has had a period of abstinence. It usually occurs prior to the actual consumption of the alcohol or drugs from which the patient is recovering, but is assuredly followed by it. Relapse is very common in the recovering community.
Alcohol contributes to nearly 80,000 deaths annually (Center for Disease Control and Prevention (CDC), 2008), making it the third leading cause of preventable mortality in the United States after tobacco and diet/activity patterns (Mokdad, Marks, Stroup, & Gerberdin, 2004). In 2005 there were more than 1.6 million hospitalizations due to alcohol (Chen & Yi, 2007). Alcohol dependence and alcohol abuse cost the United States an estimated $220 billion in 2005 in healthcare and lost productivity. This dollar amount was more than the cost associated with cancer ($196 billion) and obesity ($133 billion) (Treatment-Centers.net, 2011). Approximately 14 million people in the United States, or 7.4 percent of the population, meet the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), (American Psychiatric Association, 2000) criteria for alcohol abuse or alcoholism. Throughout the world, alcoholism accounts for 4% of the “global disease burden” (World Health Organization, 2002).
According to the Centers for Disease Control and Prevention (CDC), the disease of alcoholism creates many long-term and chronic health risks. Some of these include neurological problems, including dementia, stroke and neuropathy. Chronic alcoholics also live with the prospects of developing cardiovascular problems, psychiatric issues, higher risks of various forms of cancer, in addition to social problems (Centers for Disease Control and Prevention, 2011). These are all in addition to the commonly-known diseases which are normally attributable to alcoholism such as cirrhosis of the liver, alcoholic hepatitis, pancreatitis, gastritis, and other liver diseases (Xu, Kochanek, Murphy, & Tejada-Vera, 2010; Lesher & Lee, 1989 and Kelly, Kaufman, Koff, Laszlo, Wilholm, & Shapiro, 1995). Cirhossis of the liver is currently the 12th leading cause of death in the United States (Szabo & Mandrekar, 2010).
While a great deal of research has been conducted on alcoholism and drug addiction, much less has been done on the physical ailments of those with long-term sobriety. There has been a significant amount of research into what commonalities exist in long-term recovering people, however, the question of physical infirmities connected to their prior alcohol problem has been, for the most part, left alone. This pilot study attempts to analyze whether there are any common lingering physical effects for those with more than twenty years of sobriety and if so, do the results warrant a dissertation.
It has long been anecdotally thought that an alcoholic in recovery can completely restore his or her physical and mental health through long-term abstinence if their self abuse had not crossed the line of permanent damage. The potential damage that has caused the most concern was that done to the liver, pancreas, brain, and esophagus. We will primarily look at the liver, pancreas and the brain in this study, although it is known that for those alcoholics who smoke, cancers of the throat, especially the esophagus and the larynx, are very common (Edwards, 2004; Anderson, Chhabra, Nerurkar, Souliotis, and Kyrtopoulos, 1995).
Alcoholic liver disease (ALD) is one of the most common causes of chronic disease in the world. The severity of the damage related to alcohol varies within different individuals and even within the same individuals at different times. While laboratory tests have long been used to distinguish among the the various stages of alcohol-related liver damage, liver biopsies have been found to be the most accurate method of distinguishing among the stages and finding more covert evidence of damage (Diehl, 2002)
Alcoholic liver disease runs a spectrum of various levels of how much damage the alcoholic has done to his liver. At the less severe end of the spectrum is the condition of a fatty liver, known as steatosis. Steatosis is reversible with abstinence or a significant drop in consumption (Diehl, 2002; and, Mann, Smart, and Govoni, 2003). If the alcoholic continues to drink his liver issues will become more severe, leading to steatohepatitis, or alcoholic hepatitis, and further inflammation leading to fibrosis. These illnesses may or may not improve with abstinence. Research shows that 40% to 50% of patients with chronic alcohol- induced steatohepatitis develop cirrhosis within five years (Galambos, 1972). Further drinking will bring the alcoholic towards the most severe end of the spectrum, cirrhosis, and finally, end-stage liver disease. Both of these conditions are irreversible and create a poor prognosis for the alcoholic (Szabo & Mandrekar, 2010). The progression of ALD is caused by the continued consumption of alcohol creating a chain of events in which inflammation plays the key role. The continued inflammation will cause the alcoholic to progress from a fatty liver to liver cell death, inflammation, regenerating nodules, scar tissue (fibrosis), and finally cirrhosis (Diehl, 2001 & Tilg, Jalan, Kaser, Davies, Offner, et al, 2003). It is important to note that alcohol-induced cirrhosis may be present in individuals who have very few symptoms or signs of liver disease. However, 25% to 30% of patients will develop more clinical symptoms per decade, meaning that within twenty years more than half of the people who are diagnosed with cirrhosis will have had it in a dormant form. Diehl’s study did not address whether those in dormant form were abstaining from alcohol or continued to drink alcoholically (Diehl, 2002).
When a patient has reached the level of having cirrhosis of the liver it often creates the need for a liver transplant. This has become a controversial issue when the patient is an alcoholic (Esquivel & Keefe, 1993; Boren, 1994; and, Light, 1994). There are several reasons for the controversy. They are as follows: a) questions as to whether the alcoholic will return to drinking, recidivism; b) the possible post- operative noncompliance of the patient regarding lifestyle and diet regimens, resulting in the new liver’s failure; and, c) although alcoholism is designated as a disease, many still view alcoholism with moral overtones, therefore, the feeling exists that the need for the liver transplant is the patient’s own fault (Boren, 1994 and Light, 1994). Since an alcoholic in need of a new liver has generally shown a disregard for their own life, many have thought that a new liver would be a license to continue drinking (Esquivel and Keefe, 1993). Studies have shown this not to be the case (Berlakovich, Steininger, Herbst, Barlan, Mittblock, and Muhlbacher, 1994). A University of Michigan study went so far as to develop an “alcoholism prognosis scale” to decide which alcoholics would be accepted for a transplant. Acceptance was based on a variety of factors such as acceptance by the alcoholic and his family that he was, in fact, an alcoholic, social functioning and stability, changes in life-style with substitute activities, hope and self esteem. Fewer than 50% of those who applied were accepted based on those qualifications. The researchers found that the alcoholic’s survival rate was no different than the non-alcoholic, approximately 80%. Additionally, only a small number, 10% to 12%, returned to drinking after the transplant. Most of these did not drink alcoholically, and some only drank once. (McMillen, 1995 and Lucey, Merion, & Henley, et al, 1992 and updates).
Liver cancer is also a significant concern for alcoholics. Many studies have shown in both humans and laboratory animals that large quantities of alcohol may produce as high as a fivefold increase in the incidence of liver cancer (Anderson, et al, 1995; Naccarato & Farinat, 1991; and, Anundi and Lindros, 1992). In 2011 it is estimated that nearly 20,000 people will die from liver cancer in the United States (American Cancer Society, 2011). A second common problem for alcoholics is the function of the pancreas. Pancreatitis, an inflammation of the pancreas, is very common in severe alcoholics. Pancreatitis is life threatening because of its effect on the efficiency of the operation of the pancreas. The pancreas is a gland located behind the stomach. It releases the hormones insulin and glucagon, as well as digestive enzymes that help you digest and absorb food (National Center for Biotechnology Information, 2010). Alcohol abuse has a very negative effect on the pancreas, not only limited to pancreatitis, but also pancreatic cancer.
Nearly 38,000 people will die in 2011 from pancreatic cancer in the according to the American Cancer Society. Of all forms of cancer this ranks as third in number, even surpassing more commonly known cancers as leukemia and lymphoma. In fact, the only forms of cancer that kill more are breast and colon cancers (American Cancer Society, 2011)
A third problem for alcoholics is the function of their brain after years of abusing it with alcohol. While some studies have shown the brain to recover from the effects of alcohol with long-term sobriety, others have not (Cardenas, Studholme, Gadzinski, Durazzo, & Meyerhoff, 2007 and Gadzinski, Durazzo, & Meyerhoff, 2005). Cardenas, et al found that brain tissue volume recovers with a significant period of abstinence. Interestingly, Cardenas’ study found that drinking severity was not significantly related to the brain’s structural changes as much as length of time drinking. The results of this study are tempered by the fact that it had a relatively small sample size, limiting its prediction of how much recovery of the brain would exist (Cardenas, et al, 2007). Studies that don’t show improvement on the part of the recovering alcoholic appear to be the result, in part, to the combination of many years of alcohol abuse and the advancing age of the alcoholic (Rosenbloom, and Pfefferbaum, 2008). Specifically, abstinent older alcoholics tend to suffer from brain atrophy producing memory loss and impairments in their visual-spatial motor skills that may be a combination of the aging process and the effects of years of alcohol abuse (DiScalfani, Ezekial, Meyerhoff, Dillon, Weiner, and Fein, 2006).
In a twist of what this study is trying to ascertain, a 1992 study looked at the mortality rate of alcoholics who stayed abstinent compared to those who relapsed over an eleven year period. While those that relapsed died at a rate five times higher than those who stayed sober, it is interesting to note that the sober group’s mortality rate was similar to a non-alcoholic control group. The researchers concluded that alcoholic men who achieved “long-term” sobriety experienced the same mortality rate of the general male population (Bullock, Grant, & Reed, 1992).
Tony Foster is the director of therapy at the Beachcomber Outpatient Services Treatment Center located in Boynton Beach, Florida.