24) References.

A friend of mine has an exceptionally high IQ, and has acquired two degrees, one in law and one in economics. Not yet 30 years old, he is running his own business and is headed somewhere powerful.

He also has an alcohol problem. He acknowledges this problem and recognises that if he doesn't do something about it, he will forfeit his future and follow the well worn path of other "could have been's".

He has been to a few A.A. meetings and finds them interesting but he doesn't have the "war stories" necessary to feel part of the group. He has to be content with what they call the "Yets" - "This hasn't happened to you .... yet." The implication is that it all will happen to him if he goes on drinking. He knows this. He stops for a while. But he really likes drinking and finds it extremely difficult to stay stopped.

This program is for him and for others like him.

This section of the program is designed to provide you with motivating information. If you are still not sure whether or not you want to stop drinking, the following section should help you make up your mind. If you have made up your mind to stop drinking, the following section should provide you with all the ammunition you need to set off on your journey.

Is this your story?

Some time ago you found alcohol and you liked alcohol. In fact you may have felt that you had come home, that finally you had found something that made you feel whole. Naturally you wanted to drink whenever you could and you started to form associations, or habits around certain aspects of your drinking. You got used to drinking at certain times, at certain places and with certain people. It may be that what happened next is that you started to yearn for alcohol whenever you were not drinking or when it was getting close to the time when you could next drink. It became painful waiting to drink and then, when you did get to drink, alcohol took away the pain of waiting to drink. What you were now learning was something different to what got you started in the first place. In the beginning you learned that you liked alcohol, now you were learning that alcohol took away pain of waiting to drink. The association between pain relief and alcohol increased every time you had a drink. The learning was especially profound after a period of absence from alcohol. What may have happened next is that as a function of tolerance, you found that you needed to drink more in order to achieve the same effect and when you weren't drinking you felt empty, moody, shaky and you started to feel trapped. By now other people were commenting on your drinking and you were starting to avoid people and situations which did not involve drinking. Your drinking may have started to effect your sex life. You may have found it increasingly difficult at work, trying to put up with the dreadful way you were feeling. It began to feel that the only time when you got any relief was when you were drinking. It appeared that alcohol was the solution and not the problem. Everything was getting chaotic and you felt caught in some whirlwind with alcohol your only refuge.

Once this has happened to a person, some difficult decisions have to be made. If they keep drinking as often and as much as they would like to, they are liable to lose other things that they value including self respect, families, friends, employment, success, and a great deal of money. On the other hand, trying to reduce the amount and frequency with which they drink, in order to keep the other things they value, is torturous. To tease the appetite is a cruel thing. Many struggle valiantly to moderate their drinking. This can be an exhausting struggle.

What may happen now, is that a pattern develops of stopping, staying stopped for a while, finding it too hard, busting, drinking for a while, getting very depressed, life getting into a mess, stopping, staying stopped for a while, finding it too hard, busting etc. Some people spend their entire lives trapped in this vicious cycle of "trying" to stay stopped.

Ultimately it's you that has to decide whether or not you have an alcohol problem. Everyone else can think you've got an alcohol problem, but in the end it's something you have got to decide. It is difficult to give up alcohol and therefore it's unlikely that you will be willing to give it up unless you are convinced that it is the only alternative for you. There comes a time when you have tried every trick in the book, when, no matter what angle you take, you can no longer avoid the evidence.

The AUDIT is a very useful test you can take to help you assess your drinking. The AUDIT was derived from a World Health Organisation Collaborative Study involving six countries and is estimated at having over 90% accuracy in detecting alcohol problems.¹

To take the AUDIT simply click here

If you know that you have an alcohol problem, the next question you need to ask yourself is do you need to stop drinking or can you just cut down? Can you cut down your drinking to no more that 4 standard drinks a day (if male) or 2 standard drinks a day (if female) and be happy keeping it at that limit or will you go crazy?

It is the answer to this question that separates the true blue alcoholics from those people who have got into the habit of drinking too much in certain situations and can cut down to reasonable levels given that they break the various habits that have contributed to excessive drinking (situational heavy drinkers).

If you are an alcoholic then what happens is that the drug itself is the problem in that it triggers an appetite in you which can be quite overwhelming. Once 'triggered' you become obsessed with the desire to drink. This obsession is very powerful. Even days after you have stopped drinking you are left with a very strong desire to drink more. This occurs regardless of whether or not you have become physically dependent on alcohol.

If you don't feed that yearning with a drink for three or four days, the obsession with drinking will be lifted. You will still want to drink but the desire to drink will be different in intensity and much more resistible. This desire to drink after you have stopped for a few days is motivated by the memory of how much better alcohol used to make you feel, and by various habits you have formed around alcohol. In time this desire to drink will also leave you, given that the obsession to drink is not triggered again by the consumption of alcohol.

If you are an alcoholic, it is the drug that triggers the obsession and not the situation. In certain situations you may drink more that usual, but you don't need a situation to trigger that obsession. On the other hand, situational heavy drinkers find that in particular situations, usually social situations, they drink excessively but at other times they are able to have one or two drinks without any problem.

Both the alcoholic and the situational heavy drinker can drink in moderation. The difference is that the alcoholic finds it torturous regardless of the situation, whereas the situational heavy drinker only finds it difficult in particular situations. Predicably, then, the alcoholic is unlikely to be able to moderate his or her drinking because it will be too difficult. On the other hand, the situational heavy drinker will need to either abstain, or be very careful, in certain situations until such time as they have broken the habits that they have formed, but they will be able to drink in other situations where one or two drinks will be quite sufficient.

Whether you are an alcoholic or a situational heavy drinker is something you need to decide for yourself. It is unlikely that you will be prepared to stop drinking completely unless you are convinced that it is necessary. And the critical question to ask yourself is, once you start drinking, is it hard to stop regardless of the where you are or what you are doing? If this is the case then for you to have one or two drinks would seem as absurd as stopping a four kilometre journey to the shops after 2 kilometres. You may as well not have started in the first place.

If you are convinced that "one is too many and a thousand is never enough" this program is for you. It will help you through the period between stopping with difficulty and stopping with ease. Believe it or not, eventually you won't even think about drinking except for the odd occasion. You can be happy without alcohol. The testimonies of thousands and thousands of alcoholics is that if they stay stopped long enough, alcohol ceases to be a problem. The obsession with drinking alcohol goes within a week, the cravings can take anything from a few days up to a year, depending on the strength of the particular habit that has been formed, but generally they get weaker both in frequency and intensity as each day goes by. The memory of what alcohol used to do for you takes a lot longer to get rid of, sometimes years, but it is relatively easy to manage and also gets weaker with time and new learning.

It may feel as if you are between a rock and a hard place. However, if you are an alcoholic and choose to continue drinking you will continue to suffer and it is likely that your life will deteriorate. On the other hand, if you do choose to stop, it will be difficult at first, and you will miss alcohol, however, in time it will stop being difficult. You will cease to feel as if you are half empty whenever you are not drinking. It will be harder for you in the beginning but in the long term, whatever other problems you may have, alcohol will not be one of them.

If you believe that you have become a situational heavy drinker and can moderate your drinking to a maximum of 4 standard drinks a day (if male) or 2 standard drinks a day (if female), then you have a number of options including:

i. You can choose to do this program for a period of up to six months in order to extinguish the habits you have formed and then introduce alcohol back into your life slowly and carefully.
ii. Alternatively, you may not need to do this program. You may be able to deal with your alcohol problem by identifying the situations in which you usually drink excessively, deciding to either be particularly careful when drinking in those situations to make sure you stay within safe levels, or you may decide to abstain in those situations for at least six months and then reintroduce alcohol into those situations very carefully and slowly. The are a number of Controlled Drinking Programs which you may be able to access.

If "Alcoholic" is simply a word to label an alcohol addict and you have become addicted to alcohol then you are an alcoholic by definition. The problem with this definition is that it refers simply to being physically addicted to alcohol. In theory, once you stop drinking and get over the withdrawals, you should no longer be an alcoholic. We know this is not the case. For certain people, alcoholism is greater than physical addiction, it is something to do with wanting to drink alcohol more than wanting to do anything else.

In the A.A. language, an alcoholic is someone who is 'powerless' over alcohol. However, this definition creates problems. Taken literally it personifies alcohol, giving alcohol power. The idea is that once an alcoholic has one drink they are thrown into a mysterious compulsive state whereby they no longer decide whether or not to continue drinking, it just happens to them.

If this was the case then alcoholism would be a psychiatric disorder and it would be evident that when alcoholics started to drink they would not be able to stop regardless of the circumstances. They would be compelled to drink. This is not the case. In any alcoholic's history there is plenty of evidence of control in particular circumstances. The alcoholic is able to weigh up the situation and able to stop drinking, or reduce their alcohol intake in certain circumstances. They can choose to stop or to cut down. The issue is not one of being compelled to drink, the issue is more one of really, really wanting to drink. Wanting to drink more than wanting anything else.

Really, really wanting to drink may be experienced as a compulsion but there are important distinctions. The most important of these is that 'compulsion' creates a victim out of the person, by some mysterious process, the person cannot help themselves. Apart from the fact that this is not true, it is a psychologically dangerous way of conceptualising your problem. On the other hand, to accept that you really, really want to drink, but need to stop drinking because of the effect alcohol is having on your life allows you to have some compassion for yourself, to understand that it is indeed a noble and difficult thing you are doing, denying yourself something that you like so much, while at the same time it places both the responsibility and the ability of achieving success right at your door step.

If the A.A. concept of powerlessness is interpreted as being powerless over alcoholism then the concept is clinically useful. In this case what you are powerless over is the fact that alcohol triggers such an appetite in you that it becomes too difficult to both drink and have a manageable life. You did not want to be an alcoholic, you did not choose to be in the situation of having to make a decision between something you like doing more than anything else and everything else, but now that you are here, you need to do something about it.

These are complex issues and for you it may be of interest but it is all rather academic. It does not matter whether or not you call yourself an alcoholic.

Some people are uncomfortable with the word alcoholic whereas other people find it useful to label the problem. A.A. uses the word in a non-derogatory fashion as a means of identifying the problem as one might diagnose a disease. Once you accept the diagnosis, you know what you are dealing with and what you need to do. However, if you are uncomfortable with the word then don't worry about it. After all, people give up other substances without needing a label, for example, we do not need to label an addiction to cigarettes in order to give up smoking.

The only factor that is critical in all of the above, is for you to decide whether or not you want to cut down or to abstain. And it is unlikely you will make this decision based on theory. It is far more likely that you will make this decision based on the facts of your life.

Currently the most popular way of viewing alcohol dependence is as a maladaptive habit. "For most alcoholics, drinking has become the predominant, overlearned, and habitual response to stressful situations"² In this model, alcoholism is simply a bad habit you have learned. Drinking reinforces people, it makes them feel good, they do it again and again and form a habit of drinking. Because alcohol is addictive, after a while, when the person stops drinking they go into withdrawals. This means that the learning associated with forming a habit is intensified with the person also learning that alcohol takes away pain. If the person stops drinking and goes through the withdrawal process they will still have the memory of what alcohol used to do for them, they will still want to drink. Furthermore, once a habit is learned, it is rapidly re-learned and therefore once a person starts drinking again, it won't be long before they are drinking heavily again.

The major problem with this model is that is does not explain why some people become alcohol dependent and others don't. Why is alcohol so reinforcing for some and only mildly reinforcing for others? For many alcoholics, alcohol is enormously reinforcing from that first drink. They describe a sense of that first drink being like coming home, like feeling ten foot tall and bullet proof, that alcohol has filled the void inside of them from that very first drink. This could be a consequence of vicarious learning. Their upbringing may have taught them that alcohol makes people feel better, or they might have been in a peer group that provided a psychological frame-work for rapid learning that being drunk makes you feel good. However their are too many exceptions to the rule, too many cases of alcohol itself having an immediate and extremely powerful reinforcing effect from that first drink, independent of environment, for the learning model to be the total explanation. Certainly environment would have a powerful effect on the habit of drinking but this alone cannot explain how for the alcoholic, alcohol is such a powerful reinforcer that it eclipses all other reinforces and often becomes more powerful than two of our most powerful instincts, survival and the care of offspring.

Conversely, alcohol does not have such a powerful reinforcing effect on the majority of the population. Over 90% of people drink alcohol, and yet less than 40% ever experience any significant problems with alcohol. The people who never experience an alcohol related problem are not necessarily people with stronger ego's or higher morals. They are not necessarily people who are able to resist temptation or had happier childhoods. By and large, they are people who are simply not tempted at all. Alcohol doesn't have the same effect on them. It's nice in the way that pizza may be nice for you. You might like pizza but it's unlikely you'd sell your home and family for a slice! The rest of the population may drink alcohol but it's pretty low down on their list of reinforcers and therefore easy to resist. The learning model is not able to explain these individual differences.

It is likely that the learning model explains the process of alcoholism. What this model does not adequately explain is why alcohol is so extremely reinforcing for a small percentage of our population. It is likely that a biological explanation will complete the picture. It is likely that the degree of reinforcement a person receives from alcohol is, at least in part, biologically determined.

There is a good deal of evidence to suggest that there is a hereditary link in alcoholism. Studies show that the children of alcoholics have a significantly higher risk of alcoholism even if they have been brought up in environments where there has been no, or little, heavy drinking³. Animal studies have also supported a genetic factor in alcoholism. In 1949, Korge Mardones found that some rats, when deprived of vitamin B complex developed a craving for alcohol. When these animals were bred, Mardones found that seven generations later their off-spring preferred alcohol over water.⁴ Over the last 50 years there have been numerous studies supporting a genetic predisposition towards alcoholism.⁵ Recently US scientists from Portland Alcohol Research Center⁶ have located three gene regions that influence the susceptibility of mice to physical dependence on alcohol. The study found that mice whose cells carry particular gene regions in their chromosomes numbered 1, 4, and 11 are in greater danger of developing dependence on alcohol.

It is possible that the way that genes predispose certain people to alcoholism is by having an effect on certain neurotransmitters. These neurotransmitters include those that effect feelings of well-being, notably serotonin, enkephalin and dopamine. In addition there also may be a genetically determined difference in the degree to which alcohol can inhibit anxiety. In this case the neurotransmitters involved include gamma-aminobutyric acid (GABA) and norepinephrine. And finally, there may be a genetically determined decrease in the aversive effects of alcohol in alcoholics, notably the level of acetaldehyde in the liver.

Neurotransmitters essentially are the messengers of the brain and work together to either stimulate or inhibit behaviour. Neurotransmitters therefore play a central role in reinforcement, ie. what will make us feel good or what will make us feel bad.

"Researchers currently are trying to determine whether alcoholics with abnormal serotonin metabolite levels have specific variations in the gene that codes for the enzyme tryptophan hydroxylase, which produces serotonin from other molecules in the cells."⁷ In this theory, Alcoholics have a predisposition to lower levels of serotonin and drink, at least partly, to elevate their serotonin levels. For example, lower levels of serotonin may contribute to anxiety leading alcoholics to self medicate by drinking heavily.

Other studies have looked at the dopaminergic reward pathways. Studies have examined the role of the dopamine D2 (DRD2) gene in susceptability to drug abuse⁸. In 1990 there was considerable excitement about the prospect of an Alcoholic Gene. Kenneth Blum and Ernest Noble found that in the brains of deceased alcoholics there was a statistically significant increase in of a dopamine gene, the A1 allele of the dopamine D2 receptor.⁹ This study generated considerable research with mixed results. In one study by Comings et al, there was only a moderate increase in this allele by clients diagnosed as alcoholic, whereas there was a great increase in the presence of the allele in people with a diagnosis of both alcohol and other drug dependence.¹⁰ As acknowledged by Blum, this gene is also implicated in other behavours such manic-depression, drug abuse, excessive sex, and eating disorders. It may be that this gene is some sort of umbrella gene with regard to a wide variety of pleasure seeking behaviours including alcohol.

Alcohol induces the release of endogenous opiods in the brain. Opiate antagonists such as naltrexone lead to a decrease in alcohol consumption. It is been hypothesised that a biological predisposition to alcoholism may result from over-activity, or under-activity, of the endogenous opiods.¹¹

Further evidence of a genetic predisposition towards alcoholism is that numerous studies have demonstrated that male alcoholics and their sons have EEG changes. The amplitude of the P300 wave is found to be markedly reduced in alcoholics and their sons.¹²

And finally, studies on people who have acute reactions to alcohol have also indicated genetic involvement. An intense flushing reaction to alcohol is found in large percentages of Asian people. This flushing is caused by an insufficiency in aldehyde dehydrogenase (ALDH) which is the substance that converts acetaldehyde to acetate. (In the liver alcohol is first converted to acetaldehyde and then to acetate.) This deficiency in ALDH arises from inheritance of the variant ALDH2*2 alle.¹³ Clearly, people who have this flushing reaction are less likely to drink heavily and the rate of alcoholism amongst Asians with the ALDH2*2 alle is significantly small.

People who have a negative reaction to alcohol are less likely to drink heavily. Conversely, people who do not have this negative reaction to alcohol may have more freedom to experience the pleasures of alcohol. While Non-Asians do have adverse reactions to alcohol, these reactions, which occur in woman more than men, appear to have different mechanisms to the Asian flush response and these reactions do not always occur. Paradoxically, this is evidence that Non-Asian people who experience adverse reaction to alcohol may an increased genetic risk of alcohol dependence.¹⁴

While research suggests that some people may have a genetic predisposition to alcoholism it appears that this predisposition is a complex arrangement involving a number of different genes which influence a number of different neurotransmitters in different ways, combining possibly to increase the reinforcing properties of alcohol and decrease the aversive properties of alcohol. It is unlikely that there is any single gene that causes a disease, rather "current research points to a variety of genetically influenced characteristics that inter-act with the environment to yield phenotypic risk factors."¹⁵

Whether a genetic predisposition can be defined as a disease is debateable. Clearly genes influence behaviour and there does appear to be a biological base to the amount of reinforcement alcoholics receive from alcohol. However it may be pushing the scientific point to call alcoholism a disease as such. Saunders and Phillips point out that genetic involvement does not necessarily determine an outcome, "All human behaviours are genetic to some degree. The ability to play international level cricket, speak many foreign languages fluently, be an outstanding salesperson, climb large mountains, be highly suspicious of other people, or become a doctor are all partly due to the genetic shuffle of the available parental cards. The environment has, however considerable influence on how the cards are played. The view of the authors is that drinking behaviour, perhaps one's susceptibility to become intoxicated by alcohol, the relative degree of pleasure that alcohol brings, the speed of establishment of withdrawal symptoms, may all have a biological base. But the evidence to date is not of the robustness, extent, magnitude, or sophistication to declare that alcohol dependence is a genetic condition per say."¹⁶

The advantage of conceptualising alcoholism as a disease is that it removes from alcoholics the moral of being bad or weak, and it is used to explain the need for abstinence. Diabetes is a useful comparison. No-one would blame a diabetic for becoming a diabetic but the diabetic would be expected to take responsibility for not eating sugar. In a similar fashion, alcoholism is seen as a disease, something that separates you out from other drinkers inasmuch as alcohol triggers this powerful appetite in you. You are not responsible for getting this 'condition' but you are responsible for doing something about it.

Sometimes the notion of a disease gets confused, or misused, with the notion of being powerless. Critics of the disease concept often interpret the disease concept as meaning that the alcoholic has a mysterious disease which makes them drink alcohol. This infers that a disease can determine behaviour. Our common usage of the word disease does not refer to determining behaviour. A disease may kill us, a disease may make us feel sick, but we don't usually refer to a disease determining behaviour. Genetics may determine that certain individuals are wired to get more reinforcement out of alcohol but such wiring does not determine that they will have to drink. It is clearly nonsense to claim that a disease makes people do anything. The disease concept is not an excuse to go on drinking, its benefits are in helping the alcoholic understand that they are not responsible for the fact that alcohol has come to mean so much to them but that they are responsible for not drinking.

The degree to which a substance is reinforcing increases the probability of the behaviour being repeated. Alcohol provides reinforcement as both a positive reinforcer and a negative reinforcer.

The positive reinforcing effects include a sense of alcohol making a person feel whole, increasing confidence, increasing sociability and making everything seem right with the world. The negative reinforcing effects include reducing anxiety, and anaesthetising, or blocking out unpleasant memories.

Initially, alcohol intake is largely motivated by its positive reinforcing effects. Some people never experience alcohol induced euphoria. For them, from the start, alcohol acted as a pain reliever. For most people, however, it is the euphoria and the energising effects of alcohol that are initially attractive. In time, however, the positive reinforcing effects of alcohol are lost. Eventually, the 'pleasure' that drinking gives, is merely that it stops you from going into withdrawals. Ultimately Alcohol becomes primarily a negative reinforcer. Johnson and Fromme ¹⁷ studied the motivators of young adult drinking and concluded, "The pattern of motivation for alcohol consumption evidenced in this study, in combination with findings of other researchers, suggests that the development of drinking habits may occur in stages. In the early stages of one's drinking career, positive alcohol expectancies and subjective evaluations determine consumption. As one moves toward more habitual drinking, the perception and importance of signals indicating an unpleasant internal experience (eg., negative affect or craving) may become more important predictors of procurement." It is one of the tragic facts about any addiction. Once you have become addicted, you continue to use that drug, not because you enjoy the drug, but because when you stop you get uncomfortable, ie., you go into withdrawals and your body cries out for more. Your drinking becomes an automatic response to uncomfortable internal stimulii. In other words what you "enjoy" about the drug is the relief of the pain that the drug is in fact causing. You are using a drug that is costing you a fortune and killing you, not because you enjoy using that drug any more but because of the way you feel when you stop using that drug.

This kind of reinforcement is, however, very powerful. Consider what it means. You experience suffering not when you use the drug but when you stop using the drug. And when you have that next drink it takes away that suffering. You are giving yourself a powerful psychological message that the drink takes away pain. Intellectually you know that this is not the case. You know that the alcohol is actually causing the pain, but this is not what you experience. And this is the basis of your ambivalence. Even after you have completed the physical withdrawals from alcohol you still live with the memory that alcohol takes away pain. You can extinguish this memory but it takes time. Every time you don't feed a craving with a drink you are retraining yourself, but it takes time for this re-programming to occur.

In the first few weeks of sobriety, physical withdrawals, habits and cravings under-mine a person's resolve to stop drinking. This is by far the most challenging time and having got through four weeks of not drinking, the odds of staying stopped are significantly increased.

It would seem that having survived four weeks, having gotten over the withdrawals and being well on the way towards conquering cravings, to start drinking again at this stage would be madness.

The reason that people start drinking again after the initial four weeks is a function of human nature. We don't remember pain. We remember about pain, but we don't remember the pain itself. So people start to forget what alcohol cost them. In fact, the further people move away from the pain, the less seriously they may take the need to remain abstinent. To make matters worse, what we do remember, often in a romanticised manner, is that which made us feel really good. What is encoded in the alcoholics' memory is that period when alcohol made them feel fantastic. Deeply entrenched is the memory of that euphoria that you once got from alcohol. In the later stages of your recovery from alcohol it is this memory that you need to guard against. In time the cravings and yearning for alcohol get much easier to manage, however, in time it can also begin to seem that it wasn't that bad and instead start to remember all the good times you had.

In summary then, the first part of recovering from alcoholism involves getting over withdrawals, breaking habits and conquering cravings. The second part involves forgetting what it was you liked about alcohol in the first place. The second part can take up to four years but is much easier to manage. You simply need to avoid getting complacent.

The neurobiology of alcoholism is complex and not exactly essential reading. As we come closer to using medication to help deal with alcohol problems, however, it may be of interest to have some understanding of the neurobiological effect of alcohol.

The initial use of alcohol is as a consequence of a variety of psychosocial and environmental factors. Once alcohol has entered your body, however, alcohol itself can promote continued drug seeking behaviour by its effects on the brain. Alcohol's reinforcing effects occur because of its interactions with individual neurotransmitters within the reward centres of the brain. Primarily these neurotransmitters include the opioid, dopamine, serotonin, and gamma-aminobutyric systems.

A neurotransmitter is a chemical released by nerves, or neurons, in order that information can be communicated. Neurotransmitters therefore are essentially the messengers of the brain and work together to either stimulate or inhibit behaviour. In the reward centres of the brain neurotransmitters play a central role in determining reinforcement, ie. what will make us feel good.

Conceivably, if some people have a deficit in the neurotransmitters that make us feel good and find that alcohol boosts this deficit then we have an explanation for what could motivate alcoholism. Similarly, if we have all have a normal supply of the neurotransmitters that make us feel good but some people find that alcohol stimulates the activity of those neurotransmitters that make us feel good, making them feel even better then we could also have an understanding of the dynamics of alcoholism. Then again, another possible explanation would be if we found that alcohol was more effective in reducing the inhibiting neurotransmitters in some people giving them less anxiety and more confidence. And finally, if we found that the aversive effects of alcohol are reduced in certain people, we would be able to understand a decreased restraint in the amount of alcohol consumption.

All sort of intriguing facts have been discovered about the effects of alcohol and these neurotransmitters. The picture is still not clear, but each one of the above theories has some support. The picture that is emerging thus far is that alcoholics have lower serotonin neurons in the hypothalamus, higher levels of enkephalin in the hypothalamus, more GABA neurons in the nucleus acumbens and reduced dopamine supply at the nucleus acumbens. The following section is a brief look at the relationship between alcohol and these neurotransmitters.

i) GABA

Sedation and reduction in anxiety are two of the major reinforcing functions of alcohol. GABA is the primary inhibitory neurotransmitter in the brain. GABA leads to a state of sedation and decreased anxiety. Alcohol is thought to have direct effect on modulating GABA receptors. Experimental drugs that decrease the function of GABA receptors reduce alcohol consumption in rats.¹⁸ However, research shows that Alcohol does not always increase the inhibitory effects of GABA.¹⁹ It may be that alcohol needs to stimulate another neurotransmitter called norepinephrine in order to increase the inhibitory effects of GABA.

Alcohol also stimulates other inhibitory neurotransmitters including glycine and the inhibitory neuromodulater known as adenosine.

ii) Endogenous opioids:

Endogenous opioids appear to have a role in the reinforcing effects of alcohol. Alcohol stimulates the endogenous opioid peptides leading indirectly to an increase in dopamine. Furthermore, naltrexone, which is an opiate receptor antagonist, has been shown to reduce alcohol reinforcement, the consumption of alcohol, the frequency of relapse and cravings for alcohol in humans.²⁰

Alcohol causes the release of endogenous opiods in the hypothalamus, a region of the brain involved in the regulation of various physiological states including mood, sleep, and appetite. It is considered that the opiod system may play a role in regulating drinking behaviour. However, the nature of this role is uncertain. A biological predisposition to an under-active, or a biological predisposition to over-active opiod system have both been considered to be a cause of alcoholism. Another theory suggests that alcohol use leads to an increase in endogenous opiod activity, which reinforces the intake of alcohol.²¹

iii) Serotonin:

Studies have demonstrated that alcohol dependent people had significantly lower levels of serotonin.²² One possible explanation is that some alcohol dependent people may have a genetically transmitted deficiency of serotonin (5-HT). This neurotransmitter contributes to the regulation of mood, arousal, cognition, aggression, and impulsivity. In animal studies rats who prefer alcohol have been found to have serotonin deficiencies. These deficiencies were particularly significant in the nucleus accumens, the brain area thought to be involved in the rewarding effects of ethanol.²³

Heavy drinking may be partly motivated by an attempt to raise serotonin's levels in the brain because acute alcohol consumption elevates serotonin levels. There have been a number of studies of the effect of serotonin reuptake inhibitors and alcohol intake. Presumably, if alcohol drinking is partly motivated by an attempt to raise serotonin levels, then blocking this effect of alcohol increasing serotonin should have an effect on discouraging alcoholics from drinking. Numerous serotonin reuptake inhibitors such as Fluoxetine (Prozac), Citalopram and Ondansetron, have been studied for their effects on the amount of alcohol consumed, days of abstinence achieved and craving for alcohol. At this stage there seems to be at most only a modest effect and for some medications such as Fluoxetine, the effect appears to be limited to only a week or so. However, one of the methological problems of these studies may be that subjects in the studies weren't classified into subtypes, for example late onset versus early onset alcoholism. It may be that a deficiency in Serotonin is more a factor of people who develop alcoholism before 25 years old and therefore Serotonin Reuptake Inhibitors may be more effective in this group.²⁴

iv) Dopamine:

Dopamine is involved in habit formation, in motivation, in attention, short term memory and reinforcement. Dopamine neurones respond to different kinds of motivational stimuli. Appetitive stimuli serve to attract a person to a reward and consummatory stimuli serve to maintain a person's interest in the reward. Dopamine may also play a role in classical conditioning which is the process by which a bell rung in the presence of a reward will eventually become a motivational stimulus. In other words dopamine is involved in the learning that alcohol is reinforcing, getting into the habit of drinking and in learning to associate various people, places and things with drinking.

Dopamine neurones are extremely sensitive to alcohol. Even low doses of alcohol increase dopamine in the brain. It may be that alcohol stimulates the endogenous opioid peptides leading indirectly to an increase in dopamine. Not only does alcohol directly stimulate an increase of dopamine in the brain, but the taste of alcohol also stimulates the dopamine neurones. Other stimuli, such as food, also stimulate the dopamine neurons. However habituation, or tolerance, occurs to food-related stimuli, which does not occur with alcohol. Alcohol related stimuli therefore acquire excessive motivational properties which can eclipse other reinforces such as food, sex, family and jobs.

v) Glutamate:

Glutamate is the most prevalent excitatory neurotransmitters. By blocking a glutamate receptors subtype, NMDA, Alcohol is glutamate antagonist. Studies have shown that other NMDA antagonists produce alcohol-like properties in humans and modulate the effects of alcohol including intoxication, euphoria and sedation.²⁵ Medications that block the effect that alcohol has on glutamate, such as Acamprosate have been shown to increase the likelihood that alcoholics stayed in treatment and that they achieved higher rates of abstinence.²⁶

This is a difficult question to answer.

In 1962, a Dr. D.L. Davies published a paper entitled, "Normal drinking in recovered alcohol addicts". In this paper, Davies found that out of 93 'alcohol addicts', 7 patients had returned to normal drinking and had been doing so for over 7 years.²⁷ (Many years later it turned out that Davies had been misled and that at best only one or two of these clients had in fact returned to controlled drinking.²⁸

The finding that 7 alcoholics had been able to return to normal drinking challenged the traditional belief that once an alcoholic always an alcoholic. Over the last 20 years, controlled drinking has been a hotly debated topic amongst professionals and academics. There are some claims that abstinence is not an appropriate treatment goal for anyone. Jeffrey A Schaler, from the Department of Justice, Law and Society, at the American University, Washington DC, believes that people with alcohol problems have been brainwashed into believing that abstinence is necessary for them. According to him, "The more people believe in their ability to moderate their consumption of drugs and alcohol, the more likely they will moderate."²⁹ This is clearly nonsense. Jeffrey Schaler has a very low opinion of people with alcohol problems. Not only have they been brainwashed but their problem, the one that is costing them almost everything, is a consequence of failing to believe that they can drink moderately. Their lives can be fixed when therapists, of the non-brainwashing kind, manage to show them how stupid they have been by failing to see that they can drink in moderation if they just change those nasty negative beliefs about having a problem with controlling their drinking.

Abstinence is not something invented by therapists who want to spoil everyone's fun. Abstinence comes from the experience of hundreds of thousands of people that they have to make a choice between alcohol and other aspects of their life. Their experience is that when they start drinking they become obsessed with drinking and end up in an enormous state of conflict between wanting to drink and wanting other things such as to take care of their responsibilities to their families. Equally evident is that the obsession to drink is triggered by alcohol itself which means that if a person does not trigger that appetite they can be released from the obsession to keep drinking.

If your drinking is destroying your life and giving you very little joy any more and you know that things can only get better if you stop drinking, then abstinence is an appropriate treatment goal for you. Abstinence is very hard to achieve, at least in the beginning, but with the support of a program, it is not only achievable but believe it or not, in time, you can be perfectly happy without drinking.

If you are reading this, then it is likely you already know whether or not you have to stop. The question you may be asking is whether you can ever start again.

The experience of many alcohol addicts is that if they start drinking again even after a number of years, they find that alcohol triggers that appetite again, which means that they begin to obsess about drinking and find themselves once more in a position of having to stop drinking or lose everything. On the other hand, there are also many stories of people who drank heavily in their youth and now drink moderately. This may be because their livers are so damaged that they get sick if they drink too much; it may be because they were only situational heavy drinkers in the first place; or it may be that over time the triggering effect of alcohol loses its power.

Whatever the case, the question is rather academic. What is important right now is whether or not you need to stop drinking. In the longer term your decision on whether or not you will start drinking again will be based on your circumstances and considerations at the time. If you have already paid an enormous price for your drinking, ie. have lost everything to grog then it's unlikely you will be willing to risk it again once you've re-established your life. On the other hand, if you stop before you have lost everything because you can see the dangers ahead of you, at a later stage you may decide to test the theory yourself. It is advisable, however, to maintain abstinence for a minimum period of six months in order to allow your body to return to normal and to break away from the habits you have formed around drinking.

There are two potential problems with using other addictive drugs. The first is that you may become addicted to the alternative drug. You may substitute one drug for another. Even if you were not using the other drug, such as smoking cannabis, habitually while you were drinking, you may find that your dependency on the substitute drug increases when you stop drinking, ultimately leaving you with another problem which can be as serious as your problem with alcohol. This can be especially true if you start using benzodiazepines such as valium or serepax to help you stop drinking. A benzodiazepine addiction is frequently reported as being more difficult to kick than an alcohol problem.

The second potential problem involves a drug induced reduction of your guard against alcohol. It is not uncommon that a bust on alcohol is preceded by the use of another drug. Many people report using another drug, getting partly stoned, and then thinking, "Ah, bugger it," and reaching for their drug of choice - alcohol.

Because it is so socially acceptable, alcohol is often not thought of as a drug. And even if it is recognised as a drug, people tend to think of the illegal drugs as the dangerous drugs.

Ironically, Tobacco and Alcohol are physically the most harmful drugs. In Australia, of the number of deaths caused by drugs in 1992, 82% were caused by tobacco, alcohol caused 16%, and other drugs (the "dangerous" drugs) caused 2%.³⁰

Although tobacco is by far the most harmful drug in terms of the poisonous effect it has on our bodies, alcohol is our most dangerous drug socially. A drunk person is far more dangerous than a person stoned on heroin, cocaine, or amphetamines. Consider the following.³¹

In Australia About 40% of divorces have alcohol cited as a cause;
73% of males who commit violent crimes have been drinking; 80% of Aborigines who are jailed in the Northern Territory have been convicted of alcohol-related offences;
About 50% of adult drownings are alcohol-related;
Alcohol was present in the blood of one-third of all people killed in road crashes;
About 50% of patients admitted to hospital after drug over-dosage have also consumed alcohol.

In the United Kingdom, about 1200 fatal road accidents are considered to be directly attributable to alcohol.

In the United States, drunk drivers are involved in over 50% of all fatal motor accidents.

Alcohol is absorbed into the blood vessels of the stomach and small intestine and taken to the liver. In the liver most of the alcohol is metabolised. Firstly alcohol is converted into acetaldehyde. This is a poison thought to be responsible for alcohol related brain damage, and other adverse effects of alcohol. Fortunately the acetaldehyde is rapidly converted into acetate which is used by the body eventually producing energy.

Brain Damage:

O what fools we mortals be to let an enemy in
our mouths to steal away our brains
Shakespeare.

Alcohol related brain damage is thought to be a consequence of a high intake of alcohol and insufficient thiamine (Vitamin B1). Thiamine is necessary to metabolise acetaldehyde which is thought to cause alcohol related brain damage. Because of the critical role thiamine is thought to play in causing brain damage, it is well worth noting that if you do continue to drink, taking a daily dose of thiamine may prevent any further brain damage. (Vegemite is a good source of thiamine).

Symptoms of alcohol related brain damage include short term memory loss, lack of insight, and difficulties in organisation skills. People with alcohol related brain damage are not necessarily the delerelicted and homeless. It is interesting to know that many business executives have in fact sustained considerable degrees of alcohol related brain damage and have learned to compensate for the symptoms by employing secretaries who organise them and remind them of what they need to do!

Liver Damage:
One of the best know physical effects of alcohol is the harmful effects on the liver. The range of liver disorders goes from fatty liver, hepatitis, cirrhosis and cancer.

Damage to the Digestive System:
Heavy drinkers also have a higher incidence of acute gastritis, ulcers, cancer of the oesophagus, and chronic pancreatitis.

Damage to the heart:
The toxic effects of alcohol are also thought to cause cardiomyopathy which is a weakening of the muscles of the heart and may lead to heart failure or death.

Sex:
It provokes the desire but takes away the performance. (Shakespeare)

What more needs to be said! Impotence in men and menstrual irregularities in women are common in heavy drinkers.

Alcohol and Tobacco:
It is also worth noting that heavy drinkers are frequently also heavy Smokers and therefore are also exposed to all the harmful effects of Tobacco.

Binge Drinking:
Binge drinking is by far the most dangerous form of heavy drinking both in terms of damage to your heart and damage to your brain. If you drink 50 beers in a week, it is far better to drink 10 a night for 5 days, than 50 in two days. Even if you don't drink again for a fortnight, it would be better to drink regularly than to abstain for a period and then have heavy bout of drinking.

Alcohol is considered to have an effect on preventing coronary heart disease. In a huge study by the Centre for Clinical Epidemiology and Biostatistics at the University of Newcastle, Australia ³² it was demonstrated that one or two standard drinks 5-6 days a week reduced the risk of a major coronary event by over 60% when compared with non drinkers. It is worth noting that the risk of coronary heart disease increased in men and women who drank one or two drinks infrequently. The risk of heart disease also increased in men who took more than 13 drinks a day. Furthermore, men who drank nine or more drinks a day on one or two days a week increased the risk of coronary heart disease by two and half times, whereas men who drank three or four drinks 5 or 6 days a week halved their risk.

What all this suggest is that a couple of drinks a day 5 to 6 days a week is an effective way of reducing the risk of coronary heart disease. Heavy drinking and occasional drinking (even occasional light drinking) increase the risk.

Interestingly, binge drinking is also considered particularly dangerous with regard to the likelihood of brain damage. If you are going to drink you are therefore advised to drink small amounts regularly.

One of the indicators of alcohol dependence is tolerance. An increased amount of alcohol is needed to create the same effect. This is because the liver may metabolise alcohol faster and because of changes to the central nervous system. In the above section on the neurobiology of alcohol we saw how alcohol significantly effects a number of neurotransmitters. It appears that after prolonged use of alcohol, the brain tries to restore normal functioning by reducing the effects of alcohol. For example, short term drinking increase the inhibiting effects of GABA whereas prolonged drinking has the opposite effect and therefore more drinking is required in order to get the effects of sedation and a reduction of anxiety.(33) It appears that vasopressin (a pituitary hormone) plays a significant role in developing tolerance. In animal studies, a single dose of vasopressin results in long lasting tolerance to alcohol.(34) With abstinence, tolerance drops and less alcohol is required for the effect the drinker wants to achieve.

As discussed in the above section, long term drinking can result in the brain making adaptations to counter the effects of alcohol on neurotransmitters. When a person stops drinking these adaptations that were developed to offset alcohol's inhibitory effect now rebound in hyperexcitability. In other words, it's as if their are two competing forces, alcohol and the brain. The brain which has been working hard to counter the effects of alcohol in order to achieve balance suddenly doesn't have the opposing force and there follows a period of overexcitability which is experienced as a withdrawal syndrome. It is thought that withdrawals "represents the hyperactivity of neural adaptive mechanisms no longer balanced by the inhibitory effects of alcohol." ³⁵ Specifically, as a result of heavy drinking the glutamate system becomes hyperactive. When drinking stops, this system is not balanced by the presence of alcohol, leading to tremor, high blood pressure, sweating and seizures.³⁶ In a similar fashion, long term alcohol use may result in a decrease of GABAA receptor function. In the absence of alcohol this reduced activity of GABA may contribute to anxiety and seizures.³⁷ Medications that increase GABAA function, such as Valium and Hemineurin are widely used to treat withdrawal symptoms.

The majority of alcoholics will only experience a mild withdrawal syndrome characterised by anxiety tremors, and insomnia. These symptoms may begin as soon as 3 hours after the last drink and last from 1 to 3 days. Approximately 10% of alcoholics will go on to experience agitation, high blood pressure, severe tremulousness, heavy sweating, and confusion. Typically, this more severe withdrawal will last up to 5 days. For a few people the withdrawal syndrome can deteriorate into delirium tremens (DT's) which include hallucinations, delusions, agitation and disorientation. About 5-10% of people undergoing detoxification from alcohol also experience seizures.³⁸

Not all Alcoholics suffer from withdrawal symptoms and of those that do, only a few experience severe withdrawals, however alcohol withdrawal is potentially fatal and therefore, if you have decided to stop, it is necessary that someone keeps an eye on you. This may be a friend or relative who is able to call for help if you get into trouble.

If you do plan to stop drinking without going into a detoxification centre, or a hospital, it is well worthwhile, talking to your local general practitioner first. Your GP. may examine your health in general, particularly your pulse and blood pressure and check out your history to help you assess the likelihood of severe withdrawals.

If you are detoxing at home and have a seizure, it is important that your support person gets help. Sometimes a condition called status epilepticus occurs which is when seizures follow each other continuously with little or no interruption. This is a medical emergency and requires urgent hospitalisation.

Or if you do become disoriented, agitated and begin to hallucinate then your support person needs to get you to hospital. DT's are a medical emergency and require urgent hospitalisation.

One of the factors that can compound and complicate a withdrawal from alcohol is what's known as cross-dependence. If you have been taking benzodiazepines, (sedatives, sleepers, tranquillisers), even in small doses, it is very important that you let your doctor know. These tablets have a withdrawal syndrome all of their own which can occur after regularly taking even small doses and can complicate your withdrawal from alcohol.

It is worth noting that a withdrawal that is managed well in the early stages seldom progresses to the DT's. Managing a withdrawal well in the early stages may include medication, but is centred very much on keeping anxiety down. If you are in a place where you feel safe and are not overly stimulated, (ideally, someone who you trust to keep an eye on you, a mattress on the floor if you feel safer, not much clutter in the room, lighting to suit you, and not expected to do anything, not even to participate in conversations) then it is likely you will have few, if any symptoms, and after a day or two will be ready to concentrate on the hard part - staying sober!

Giving up alcohol is a combination of:

a) withdrawing from the drug,
b) breaking habits,
c) and forgetting.

Giving up alcohol is largely a function of time. The time it takes to break the habits you have formed around drinking, and the time it takes to forget what it was that you used to like so much about drinking. Generally, as each day goes by the hold alcohol used to have over you gets weaker and weaker until such time as you won't be able to remember what all the fuss was about. In periods of abnormal stress, or when suddenly faced with a situation which you used to associate with drinking, a craving may suddenly get strong again, but once the situation has passed, the frequency and intensity of cravings will return to that more in line with the time that has passed since your last drink.

Withdrawing from alcohol is the first part of quitting alcohol. Usually this first stage of over-coming an alcohol addiction lasts about four days. It can be a pretty awful four days but after that, it is over. Your physical addiction to alcohol is over.

Breaking habits is the next part of the journey. You will have formed all sorts of habits around drinking. For example you may not be able to remember when you last had an evening meal without alcohol. If you start having your evening meal without alcohol it is likely that initially you will feel on edge, not enjoy your meal very much, and have cravings. It may feel as if you have to force yourself to eat. Keep eating your meals without drinking alcohol and within about a week or so, you will find that you sit down to a meal without even thinking about drinking. What has happened is that you have retrained your nervous system, breaking the association between dinner and alcohol.

Habits are not only associated with external stimuli. It is likely that you have also associated all sorts of different emotions with drinking. These stimuli can also elicit cravings. For example, if you have associated anxiety with drinking, every time you become anxious you may have the added disadvantage of also triggering a craving. At times like this it can feel that you absolutely have to have a drink. This is not the case, the craving will pass, you will retrain your nervous system and eventually you will be able to experience the full range of emotions without associating the feeling with a desire to drink.

Breaking habits involves not responding to the stimulus with a drink. Each time you fail to respond with a drink you are rewiring your body with different information until such time as the stimuli that used to elicit cravings fails to trigger cravings.

The length of time it takes to break habits varies according to strength of the habit and to the frequency with which the stimulus is denied the conditioned response, ie. craving alcohol. Consider the following two examples: If for five years, you have been in the habit of going out with a drinking buddy every Friday night, it will take a long time for Friday night to come around and for you not to even think about drinking. However, you may have been drinking every night with your evening meal for an even longer period and yet this habit is likely to extinguish faster than the Friday night habit because meals also involve eating food (at least for some people!) and it is something which you continue to do every night, ie. it is a daily routine, and is not specially about drinking. Further, because you continue to eat every night, you will be confronting the old learning more often and therefore might surprise yourself to find that after 4 or 5 days you've had a meal without even thinking about alcohol. On the other hand, the habit you have formed around that particular friend of yours that you only see once a week may be harder to extinguish because you are not confronting it as often. Furthermore this habit may have a number of other habits associated with it. For example, you may usually have some social anxiety when you are with this person, and therefore have two stimulii demanding a drink. You may also be used to drinking in certain environments, eg. a pub and have a whole heap of other stimulii also associated with this friend and drinking. As you can see, you may decide to avoid that friend and that pub for a while. Or you could decide to only meet that friend in situations that do not involve drinking eg. going to the gym. Even then, you need to be super aware when you are around this person and have back up supports, eg. an escape excuse, limited time with the person, and access to the Web Remedy line. Some friends you may want to eliminate from your future. Other friends you may want to keep in your life, be careful and be conscious of what's going on for you, don't drink with that person and one day you will find that you don't even think of drinking when you see that person.

Be warned though. Habits are very rapidly relearned. If after 2 weeks of having dinner without a drink, you then have a drink with your dinner, it will feel like you have to start all over again in breaking that association.

Just remember, breaking the habit is about failing to respond to the trigger with a drink. If you don't feed cravings they do go away. However, if you do give in and have a drink the association between that trigger and alcohol will have become even more entrenched.

The final part of your journey is forgetting. While most habits are broken within a month, and only the stubborn ones persist after 6 months, forgetting takes much longer. You have a memory imprinted in your brain that alcohol makes you feel whole, makes you feel fabulous, takes away all your insecurities and makes you feel ten foot tall and bullet proof. It is probably a long time since alcohol actually made you feel that good. Nowadays alcohol probably only helps you get out of bed and get through the day, but this memory deceives you into believing that alcohol will still do what it used to do, for you. It is likely that this memory will remain with you all your life. What happens is not that you will actually forget what alcohol used to do for you , it is more likely that you will build competing memories that, over time, force the memory of what alcohol used to do back into the background. One competing memory that you need to actively keep with you is how much pain and suffering your drinking caused you and the people you care about. It's not that you need to walk around all day in pain, just that you actively retain the memory of what alcohol cost you. A friend of mine says she keeps the cost of her drinking days in her peripheral vision all the time. It's not in front of her face but it is always there to remind her of what the price of drinking was for her. Another way of doing this is to write down what your drinking cost you and then get something that symbolises that cost, it can either symbolise a specific incident or the general cost, and keep it with you always. A 'photo of someone whom you hurt in your drinking, a ring, or a letter will do. A.A. is probably the most effective means of maintaining the competing memory of how much alcohol cost you. By sharing at meetings about the way it was and the way it is now, members remind each other that their drinking caused them enormous pain and suffering.

Other competing memories that you build over time are the happy times you have when you are not drinking. Right now, it may seem that being happy and not drinking are inconceivable. However, as each occasion happens where you are happy and not drinking, you begin to confront that belief until such a time when you won't be able to believe how insane you were to believe that your happiness was dependent on alcohol, when in reality, the opposite was true, your unhappiness has been caused by alcohol.

Probably the most critical factor in deciding your success or otherwise is the degree of commitment you have to abstinence. I bumped into a friend in the supermarket one day. He had just stopped smoking. We discussed the various difficulties which he shrugged off quite easily. He said, "I just keep it in the front of my brain, not to have that first one. After all, if I do that, I'm pretty much invincible."

In order for you to be invincible, you need to be aware of the factors most likely to under-mine your resolve have been extensively studied. William DeJong, describes these factors. ³⁹

1. Stress, either due to negative events in your life or just the daily grind.
2. Negative emotions which include anger, anxiety, depression and frustration. In a study by Gold and Miller, depression was the most frequent reason given by alcoholics for relapsing.⁴⁰
3. Interpersonal conflict, especially with family members can be particularly difficult.
4. Social pressure can be overt with people pushing you to have a drink, or covert, by feeling excluded because you are not drinking.
5. Positive emotions often lead to wanting to reward oneself or to celebrate.
6. Use of other substances can trigger cravings for alcohol, and reduce your ability to resist your desire to stop drinking.
7. Presence of drug related cues, as discussed above.

The general advice is to avoid hazards whenever possible. Some people try to test their motivation by deliberately putting themselves in hazardous situations. This is making it unnecessarily difficult. As a function of time, most of these hazards will lose their power and, in the mean time, you may as well make it as easy as possible.

However, there are times when you cannot avoid a hazard. In this case the most important thing is to be prepared. By working the Web Remedies program, you will be able to prepare for most anticipated hazards.

One form of medication that has been available since 1948 is Antabuse (disulfiram). This drug interferes with the metabolism of alcohol by blocking the break down of acetaldehyde. (Alcohol is converted to acetaldehyde in your liver and then rapidly broken down to acetate). Acetaldehyde is a poison which causes a number of unpleasant symptoms such as a flushed face, headache, palipations, nausea, vomiting, and breathing difficulty. If you drink on Antabuse you will most certainly wish you hadn't. One problem with anatabuse is that you have to be motivated to take the antabuse every day. Presumably, if you do plan to drink you just won't take the medication. Interestingly, one study found that when the wives of alcoholics supervised the medication it was much more successful!⁴¹ It is possible to have Disulfiram surgically implanted. However this does mean having to have surgery relatively regularly and there is some doubt as to whether this method is able to produce a sufficient amount of Disulfiram in the blood to have the aversive effect.

Disulfiram may be of use to you if you have to go into a high risk situation such as a wedding and would like that extra bit of motivation not to drink.

In the last few years there has been a considerable interest in the effectiveness of medications which alter the effects of neurotransmitters in helping people either reduce the amount of alcohol they drink or in helping people stay sober.

As discussed above, neurotransmitters such as dopamine, serotonin, gamma-aminobutyric acid and norepinephrine appear to play a significant part in alcoholism. It follows that if alcohol reinforcement is related to the effect that it has on neurotransmitters, then medications that block this effect should result in a decreased interest in drinking alcohol.

Medications are being trialled that modulate dopaminergic and serotonergic pathways. Numerous serotonin reuptake inhibitors such as Fluoxetine (Prozac), Citalopram and Ondansetron, have been studied for their effects on the amount of alcohol consumed, days of abstinence achieved and craving for alcohol. At this stage there seems to be at most only a modest effect and for some medications such as Fluoxetine, the effect appears to be limited to only a week or so.⁴² However, one of the methological problems of these studies may be that subjects in the studies weren't classified into subtypes, for example late onset versus early onset alcoholism. It may be that a deficiency in Serotonin is more a factor of people who develop alcoholism before 25 years old and therefore Serotonin Reuptake Inhibitors may be more effective in this group.⁴³

One medication that does appear promising is Buspirone. Buspirone is a non-benzodiazepine partial serotonin agonist with anxiolytic properties. A study by Kranzler et al., "indicated that this agent led to a greater likelihood of completing treatment, reduction of anxiety symptoms, a slow rate of heavy alcohol relapse, and more days of abstenence during the follow-up period."⁴⁴ Other studies have not been as promising as the Kranzler study. However even if Buspirone's does only have a modest effects on alcohol intake, its additional effects on reducing anxiety, which is a fairly common problem amongst alcoholics, make this medication an attractive proposition.

Glutamate is the most prevalent excitatory neurotransmitters. Alcohol is glutamate antagonist which brings about a number of the effects of alcohol including euphoria and sedation. Medications that block the effect that alcohol has on glutamate, such as Acamprosate have been shown to increase the likelihood that alcoholics stayed in treatment and that they achieved higher rates of abstinence.⁴⁵

Promising results have also been achieved with naltexone. It is considered that opioid system plays a role in the regulation of drinking behaviour. Naltrexone, is an opiate receptor antagonist and has recently received much press related to its effects on heroin addiction. It has also been shown to reduce alcohol reinforcement, the consumption of alcohol, the frequency of relapse and cravings for alcohol in humans.⁴⁶ In Australia Naltrexone is now subsidised by the government to help people with alcohol dependence and you are well advised to talk to your G.P. about using it.

Much of the work on medication that alters the effects of neurotransmitters is still at laboratory stage. However, it does appear evident that in the not too distant future medication will be a common adjunct to therapy. It is unlikely, however, that medication alone will be sufficient to help people over-come alcohol problems. The memory or what alcohol used to do for you, the habits you have formed, and social pressure are all components of your alcohol problem which have to be dealt with in order for you to achieve long-term success. Medication may make the process easier. And there is nothing at all wrong with making it as easy as possible. In fact, combining this program with medication could render you bullet proof. This program can help you break the psychological habits, and medication can help you over the physical addiction. If you are interested in taking medication, consult your G.P. to see what is available in your country.

Meditation can be very useful in over-coming an addiction, both because it can help in keeping people grounded and therefore more in touch with their goals, and because it can help in mood management.

The major difficulty with using meditation to assist giving up drinking is that many people find it difficult to concentrate when they first stop drinking. For this reason, the following simple meditations may be of value.

Firstly, set an alarm clock for ten minutes (when you have become comfortable with 10 minutes you can increase the time to 15 minutes and later to 20 minutes which would seem an optimum time to do these exercises). Now choose one of these two meditations.

The first involves breath counting. Sit or lie somewhere where you feel comfortable. Now simply count silently each time you breathe out, up to four, and then start again. If other thoughts come in, as they will, simply bring yourself back to focus on the counting. The aim is to focus entirely on the counting and think of nothing else. If you haven't tried meditation before, you may be surprised at how difficult it is to shut your head up!

The second method involves mantras. The mantra you choose can be either meaningful or meaningless depending on what makes you feel comfortable. Here are some suggestions: Hare Krishna, Kyrie eleison (Lord have mercy), Love one another, Help me, Heave-ho, Ulla-dulla, I can do it, God is good, or whatever! Sit somewhere comfortably, and start chanting the phrase. It is preferable to do this aloud but not too loudly. Keep trying to focus on the chant and nothing else. Whenever you find yourself wondering off, bring yourself back to focussing on the chant.

When the time has expired after either of these exercises, try to sit for a few minutes, with your eyes shut, making every effort to think of absolutely nothing. And then open your eyes, take a few deep breaths and you'll probably be amazed at how much better you feel, and how much readier you feel to deal with life's trials and tribulations.

For meditation to be effective it needs to be done regularly. Like physical exercise, exercising the mind needs to be part of a regular program.

One of the reasons you may have been drinking is the effect that alcohol has on masking anxiety or depression and making you feel more relaxed. It is estimated that up to 19.4% of alcoholics have anxiety disorders and 13.4% have mood disorders.⁴⁷ When you stop drinking you may have trouble with anxiety, depression and/or anger. For some people, these moods can be very difficult to manage and may contribute towards giving up the struggle of giving up alcohol. In this section some options are presented for managing these emotions.

• Medication: Of interest is that the same areas of the brain and their relevant neurotransmitters (dopamine, serotonin, GABA) have also been implicated in the pathogenesis of several mental disorders including depression and anxiety. For example, a serotonin deficiency is thought to increase vulnerability to anxiety, mood disorders, impulsivity, aggressiveness, and alcohol seeking behaviors.⁴⁸ "Thus medications that impact upon these neurochemical systems may not only have effects on the psychiatric disorder but also on the concurrent addictive disorders."⁴⁹ Fluoxetine (Prozac) is a Serotonin Uptake Inhibitor which is commonly used for treating depression. It has also been shown to have a modest effect on alcohol consumption levels, days of abstinence, and cravings for alcohol.⁵⁰ However the effect of Fluoxetine appears to wear off fairly quickly. A study by Gorelick et al., showed that the effects only lasted one week.⁵¹ Buspirone is a non-benzodiazepine partial serotonin agonist with anxiolytic properties. A study by Kranzler et al., "indicated that this agent led to a greater likelihood of completing treatment, reduction of anxiety symptoms, a slow rate of heavy alcohol relapse, and more days of abstinence during the follow-up period."⁵²

• An important tool when managing anxiety or anger is to understand that these feelings will pass. When you are feeling very anxious or angry, it can feel that these uncomfortable feelings are base emotions that you will have to endure forever if you don't have a drink. This is not the case at all. In fact, your drinking is probably the root cause of the intensity of this problem. The intensity with which you may experience these feelings are part of the normal process of giving up alcohol and will end. There are a number of things you can do, to help yourself to over-come these feelings without having a drink. In fact if you feed the anxiety or anger with a drink, you will probably make the situation worse for yourself. By drinking you strengthen the association between drinking and feelings and made it harder for yourself.

• A very simple technique to deal with these emotions is deep breathing. Take ten very deep breaths before you do or say anything and you may find that the feelings start to abate.

• In the first few months of quitting drinking, try to avoid stressful people and situations. Remember, you are doing something very difficult, something for yourself, but also something for everyone who cares about you. So, by taking care of yourself, even if at times it looks as if you are being selfish or foolish, you are in fact decreasing the chances of relapsing and ultimately helping everyone who cares about you.

• A funny thing about humans and feelings, is that talking about the feeling has the effect of releasing the pressure. In our society we have a tendency to be strong, to try and do life without letting people see our fears. The effects of being strong include isolation, anger, fear of cracking, self righteousness, stress, tension, bitterness and loneliness. The irony is that it is a strength to be vulnerable. It is difficult to talk honestly about what you are feeling, especially in the beginning, but the effects are fabulous, you become part of the human race, you stop having to pretend all the time, you give permission to other people to be honest with you, your relationships become deeper, and you become able to give and receive love. Talking about your feelings isn't about being sorry for yourself, or ending up a boring, self centred person, and talking about your feelings isn't about expecting people to rescue you, talking about your feelings is just about being honest about what's going on for you and by doing that you will decrease the intensity of anger and/or anxiety, and increase your chances of staying stopped.

• Watch out for negative thoughts. Anxiety and/or anger is often preceded by negative thoughts. If you allow yourself to believe dreadful things about yourself, you are going to feel pretty bad and that's going to make it hard to keep faith in your ability to succeed. If this is a particular problem for you, if you have a really low self esteem and are in the habit of putting yourself down, you may consider getting counselling. This way you can kill two birds with one stone - quit drinking and fix that destructive thinking. Transactional Analysis, or Cognitive Restructuring are two of many useful therapies for dealing with this problem.

• And, finally, remember that feelings are not real things. In our society we seem to have got pretty muddled about the power of feelings. If somebody does something wrong, we often hear the excuse, well he was feeling bad. Feelings are motivators, they may make us want to do something, but they can't make us do anything. This is an important distinction that every successful person knows. A successful person does not say, I'm feeling bad so I'll miss that very important appointment. A successful person does what they have to do regardless of what they are feeling. A successful person may repress their feelings, in which case, they may end up successful and bitter and twisted. Or a successful person may learn to express their feelings in appropriate ways, but not allow their feelings to determine their life, in which case they end up successful and healthy. By giving up drinking alcohol, you may end up feeling angry and/or anxious. If you give in to these feelings and have a drink, you will feel worse about yourself. If, on the other hand, you deal effectively with the anxiety and/or anger, and the feeling passes without having been fed a drink, at the end of the day, you will have achieved something very important for yourself.