• Michelle Bakke made a very good point in her answer: you can be a problem drinker without being an alcoholic. Alcohol use and dependence affect approximately 14 million individuals in the United States with an estimated economic cost of $134 billion from loss of productivity. Alcohol use disorders directly and indirectly cause many adverse health outcomes.

    Epidemiologic data show an increase in morbidity when daily consumption exceeds two drinks. The Centers for Disease Control defines excessive drinking in men as 5 or more standard drinks in one sitting or 15 or more standard drinks per week. In women, 4 or more standard drinks in a sitting or 8 or more per week are considered problematic. A standard drink represents 14 grams of pure alcohol. Here’s the link: @CDC – Fact Sheets-Alcohol Use And Health – Alcohol. Even apart from alcoholism, the effects of alcohol are toxic over the long-term

    A study by the National Institutes of Alcohol Abuse showed that seventy-five percent of adults in the U.S. never exceed the limits of the screening question. Although alcohol related problems can be associated with one occasion, like driving when intoxicated, and it also rises with the number of heavy drinking days.

    There are a variety of instruments used by doctors to screen patients for alcohol use disorders. A positive screen should be followed by a complete evaluation by a healthcare professional.

    Screening provides a rapid initial assessment of substance use severity and identification of an appropriate level of treatment. It can be followed by a brief intervention that focuses on increasing insight and awareness as well as motivation for behavioral change. Available screening instruments that are widely used are sensitive and specific for problem drinking and for dependence. Questionnaires are more sensitive for alcohol dependence than the many blood tests available to measure biomarkers of alcohol abuse. Many screening questionnaires rely on self-report, but most people are willing to answer screening questions honestly for their healthcare provider. The following tools are available online.

    A commonly used screening tool for alcohol disorders, the CAGE questionnaire consists of four questions.

    Two or more positive responses in the CAGE questionnaire are strongly associated with dependence. The CAGE questionnaire asks:

    • Have you ever felt you should Cut down on your drinking?
    • Have people Annoyed you by criticizing your drinking?
    • Have you ever felt bad or Guilty about your drinking?
    • Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (Eye opener)?



    For current drinkers, the test has a sensitivity of 53-69% for detection of unhealthy alcohol use in patients who answer yes to two or more questions, and for alcohol abuse or dependence of 77% in these patients. Specificity has been demonstrated between 70 to 97 percent and 79% respectively.

    Other tests that are commonly used include the AUDIT and AUDIT-C questionnaires. (The Alcohol Use Disorders Identification Test is a publication of the World Health Organization, @ 1990)

    This is the AUDIT-C questionnaire:

    Q1: How often did you have a drink containing alcohol in the past year?

    Answer-Points

    Never – 0

    Monthly or less – 1

    Two to four times a month – 2

    Two to three times a week – 3

    Four or more times a week – 4

    Q2: How many drinks did you have on a typical day when you were drinking in the past year?

    Answer-Points

    None

    I do not drink – 0

    1 or 2 – 0 –

    3 or 4 – 1

    5 or 6 – 2

    7 to 9 – 3

    10 or more – 4

    Q3: How often did you have six or more drinks on one occasion in the past year?

    Answer-Points

    Never- 0

    Less than monthly- 1

    Monthly- 2

    Weekly- 3

    Daily or almost daily – 4

    The AUDIT-C is scored on a scale of 0-12 (scores of 0 reflect no alcohol use). In men, a score of 4 or more is considered positive; in women, a score of 3 or more is considered positive. Generally, the higher the AUDIT-C score, the more likely it is that the patient’s drinking is affecting his/her health and safety.

    Here are some statistics about the accuracy of the AUDIT-C:

    Unhealthy alcohol use: Sensitivity 57-95%; Specificity 78-96%

    Abuse or dependence: Sensitivity 61-96%; Specificity 85-96%

    I think it’s a safe bet your husband will have a positive screen for some type of alcohol use disorder. It’s important to follow this up with a complete evaluation by a physician who is experienced in diagnosis and treatment of alcohol and drug use disorders.

    The guide to psychiatric diagnosis, known as the Diagnostic and Statistical Manual, is in its 5th revision. This revision classifies alcohol abuse and dependence along a continuum of alcohol use disorder. Diagnosis of alcohol abuse requires the presence of one or more of the following: role failure, risk of harm, legal troubles, or relationship troubles.The diagnosis of alcohol dependence requires presence of three symptoms associated with dependence in a twelve month period. Here are the symptom areas:



    Taking the substance in larger amounts or for longer than the you meant to

    Wanting to cut down or stop using the substance but not managing to

    Spending a lot of time getting, using, or recovering from use of the substance

    Cravings and urges to use the substance

    Not managing to do what you should at work, home or school, because of substance use

    Continuing to use, even when it causes problems in relationships

    Giving up important social, occupational or recreational activities because of substance use

    Using substances again and again, even when it puts the you in danger

    Continuing to use, even when the you know you have a physical or psychological problem that could have been caused or made worse by the substance

    Needing more of the substance to get the effect you want (tolerance)

    Development of withdrawal symptoms, which can be relieved by taking more of the substance.

    I mentioned biomarkers previously. One role of biomarker assessment in treatment of alcohol use disorders is to provide a screening tool for individuals who abuse alcohol. Laboratory evaluations of indirect biomarkers of alcohol consumption are significantly more expensive and less sensitive for detection of unhealthy alcohol consumption compared to screening questions. These tests reflect organ damage resulting from alcohol consumption, including gamma-glutamyl transferase, aspartate aminotransferase, carbohydrate-deficient transferrin, and macrocytic volume. unable or unwilling to accurately report drinking behavior.

    MCV, GGT, and AST are indirect tests that reflect manifestations of organ damage that is often the result of alcohol consumption. It is uncertain that the patient has consumed adequate quantities over an adequate duration of time to produce organ damage resulting in elevated biomarkers. These biomarkers can be used to assess the contribution of alcohol to disease. They indicate prolonged heavy consumption and return to normal in most cases after several weeks of abstinence. Gamma glutamyl transferase (GGT) is a sensitive marker for ethanol-induced liver damage. AST elevations often occur in people who abuse alcohol, but sensitivity for detection of heavy alcohol consumptions is only 25-60%. Anyway, you already know how much your husband drinks. Macrocytic volume (MCV) reflects changes in hematopoesis, or formation of blood cells. MCV increases in relationship to the amount and frequency of ethanol consumption, but in most cases, ingestion of more than 60 grams/day for longer than a month is necessary to increase MCV above normal range. It is a less sensitive test compared to GGT in alcohol abusers and there are a variety of diseases that can cause an elevated MCV, including hemolysis and vitamin deficiencies. However, if elevated, it may help you get your husband’s attention.

    Reassure your husband that a variety of helpful options are available for care. Many people don’t seek help because they aren’t aware they have a choice.

    The standard of care in evaluation and determination of the necessary level of treatment for patients with drug or alcohol use disorders is the American Society of Addiction Medicine Patient Placement Criteria (2nd Revision). A thorough assessment of six “dimensions” takes individual characteristics into account when determining the severity of the problem and indicated level of care. The dimensions considered in the ASAM PPC-2R include:

    1: Acute Intoxication and/or Withdrawal Potential

    2: Biomedical Conditions / Complications

    3: Emotional, Behavioral or Cognitive Conditions / Complications

    4: Readiness to Change

    5: Relapse, Continued Use or Continued Problem Potential

    6: Recovery/Living Environment

    Patient-directed treatment will result in placement at the lowest intensity of care that will be both safe and effective for the patient. In other words, the best doctors tailor individual treatment in consultation with their patients, taking patient needs and desires into account. There are no “one-size-fits-all” solutions for treatment of alcohol or drug dependence.

    Here are some short descriptions of the levels of treatment that are available:

    Level I Outpatient Treatment

    Level II.1 Intensive Outpatient

    Level II.5 Partial Hospitalization

    Level III.1 Clinically Managed Low Intensity Residential Services

    Level III.3 Clinically Managed Medium Intensity Residential Treatment

    Level III.5 Clinically Managed High Intensity Residential Treatment

    Level III.7 Medically Monitored Intensive Inpatient Treatment

    Level IV Medically Managed Intensive Inpatient Treatment

    Only 20% of people who need substance abuse treatment actually receive help. Alcohol withdrawal can be medically dangerous, however, so your husband should enlist the help of your family practitioner or another doctor.

    After that, it’s pretty much up to him. It’s worth noting that many people quit drinking on their own. I wrote about that in another answer: @Karen B. Shackelford’s answer to Do alcoholics have any other options besides the AA?

    The natural course of alcoholism ends in remission for 75% of people identified as alcohol dependent. This information is supported by data obtained from the 2009 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), the largest survey of Alcohol Use Disorders ever conducted in the United States. The study was conducted by the National Institute on Alcohol Abuse and Alcoholism (NIAAA), a government agency. The cross sectional data from the NIAAA is also supported by longitudinal studies, The study found that three fourths of people with alcohol dependence (otherwise referred to as alcoholism) overcame it and of those people, three-fourths did it without going to any AA meetings, rehab facilities, or treatment programs!



    TL;DR: Your husband has an unhealthy pattern of alcohol consumption. He is somewhere along the continuum of abuse and dependence. He needs a complete evaluation by a qualified medical profession for diagnosis, but my money says he is dependent. He shouldn’t detox without consulting a doctor. Good luck.

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