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Colin MacKenzie M.D.
December 12, 2020

Stages of Alcoholism

Introduction

Approximately 14 million US adults, age 18 and over, and 400,000 adolescents, age 12 to 17, fulfilled criteria for an alcohol use disorder (AUD) in 2018.  Alcohol use disorders, in the majority of cases, begin early in life and have a typical pattern of escalation.  This blog will provide insight into alcoholism and its stages.  We will present the first stage here with others to follow in subsequent blogs. 

Alcohol Use Disorders & Alcoholism 

Alcohol use disorders are a set of defined substance use disorders that are described in the Diagnostic and Statistical Manual of Mental Disorders – Fifth Edition, which is used for diagnostic purposes by clinicians. The pattern, chronicity, and severity of alcohol use disorders varies widely.  However, for diagnostic purposes, the DSM-5 segregates alcohol use disorders into different types based on a limited number of criteria with severity categorized as “mild, moderate, or severe”. 

Alcoholism is a colloquial term that refers to a pattern of alcohol use that leads to mental or physical health problems that may be mild or severe. Many use the term “alcohol addiction” interchangeably with alcoholism. 

The term “alcoholic” is also a colloquial term used in reference to a person who suffers from an alcohol use disorder. 

The terms “alcohol abuse” and “alcohol dependence” have been phased out of formal diagnostic use, but are still used by clinicians informally to make clinical distinctions between different patterns and chronicity of alcohol use disorders.   

Different Stages

Alcohol use disorders have a variety of different patterns of use with a wide range of chronicity and severity.  Sometimes a person’s alcohol use disorder will continue for a limited period of time and remain at a mild degree of severity before resolving completely. In other circumstances, a person’s alcoholism may have intermittent, but lengthy, periods of sobriety over many years.  In other cases, the disorder will follow a steady pattern of increasing severity to the point of compromising one’s health and social wellbeing. 

This blog will outline this latter pattern of alcoholism that typically starts in one’s teens and progresses to a severe stage later in life. This pattern of use can be divided into four stages:

  • Pre alcoholic or “at risk” stage
  • Early alcoholic stage
  • Middle alcoholic stage
  • Late alcoholic stage

Recognizing the different stages of alcoholism can be helpful if you are worried that you or someone you know may have an alcohol use disorder,

Photo by cottonbro from Pexels

Pre-Alcoholic Stage

The pre-alcoholic stage is the first stage of alcoholism which generally starts in the second decade of life, though sometimes it may not be evident until the third or fourth decade.[1] It is characterized as experimentation and “pushing the limits” of one’s use of various kinds of alcohol and testing one’s tolerance. It often begins with occasional drinking in social gatherings, but often devolves into a social “competition” where the quantity of use is a measure of one’s machismo, sex appeal, courage, or risk taking.  Binge drinking is common, especially in competitive social situations. As the stage progresses, the frequency and quantities used increase, and the pattern of use may transform from solely social circumstances to use while alone for stress reduction or control of other symptoms such as anxiety, depression, or physical pain.  Tolerance, where increasing amounts are needed to achieve the same effects, may occasionally occur if alcohol use occurs several times per week.  Significant withdrawal symptoms are rarely seen at this stage. 

Binge Drinking

Binge drinking is quantified as a blood alcohol content (BAC) of 0.08 or higher within two hours.[2

  • In men, depending on body weight, it generally takes five drinks in two hours to reach this BAC value, whereas
  • In women, this generally requires four drinks.

Going beyond the four or five drink limit is likely to lead to higher blood alcohol concentrations alongside a variety of physical and mental side effects. Immediate effects include nausea, vomiting, and loss of coordination. However, the BAC can achieve levels that lead to severe sedation, respiratory depression, and liver damage. It can also lead to coma, followed by death.

The following table is a guide of BAC and corresponding effects:

 

Blood Alcohol Levels and Corresponding Effects

 

BAC

gm/dl

Effects

0.02

This level of BAC is when most people experience the first feeling of intoxication with relaxation, increased impulsivity, warmth, mood changes, and increased confidence. 

0.05

Moods become more labile and exaggerated. Socially inappropriate behaviors may occur with some incoordination, impaired judgment, decreased reflexes, and more difficulty with vision. 

0.08

This is the current legal limit for operating an automobile in the U.S.  This is because coordination and judgement become grossly impaired with difficulty with reflexes, ability to stand on one foot, walk heal to toe, or react to avoid an object or a fall.  Speech is often slurred and concentration and short-term memory are impaired. 

0.15

At this level, stumbling and falling are common, talking coherently is difficult, and cognitive functions are further impaired. 

0.20 to 0.29

Alcohol induced delirium begins with a stuporous sensorium, gross confusion and disorientation.  Awareness of one’s surroundings, awareness of imminent threats, and pain sensations are reduced Blackouts often occur (lack of memory for events at the time).   Assistance is needed to walk.  The Gastrointestinal system will attempt to detoxify the body through vomiting, however a decrease in sensorium and gag reflex can lead to aspiration and suffocation. Protection of the airway is needed. 

0.30 to 0.39

Autonomic nervous system function becomes grossly impaired with increased or irregular heart rate, hypotension (low blood pressure), depression of respiratory drive, loss of bladder and bowl control, and waxing and waning consciousness. 

0.40 or greater

Risk of comma and death are greatly enhanced with further compromise in consciousness, abnormal cardiovascular function, respiratory arrest, and deadly cardiac arrhythmias. 

 

Social and Behavioral Changes

During this stage, there is little to no evidence of problems with alcohol and your behavior may seem normal to a casual viewer. You may be drinking more frequently than those around you, but it is not obvious to everyone. You may develop a liking to the feeling you get from drinking and the occurrence of binge drinking may increase.  

Indications

If you are consuming alcohol repeatedly to make yourself feel good, to forget unpleasant experiences, to escape distress, to decrease stress, or to alleviate physical pain, you may have entered the pre-alcoholic stage. 

Treatment

If you believe that you are at this stage and you want to gain better control of your alcohol use, professional counseling and group therapy may prove to be useful. 

Stay tuned for further blog entries regarding the stages of alcoholism.