Crossing the Line: Women and Alcoholism
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Crossing the Line: Women and Alcoholism

The number of women abusing alcohol is on the rise. And the signs of addiction are far more subtle than you might imagine.

The Rise of Female Consumption

Two or three times a week -- "sometimes less, rarely more" -- Anne Calais,* an elementary school teacher and energetic mother of two, enjoys a vodka martini or a glass of wine with dinner. Occasionally, on Friday evenings she and her husband sit with a drink in front of the fireplace in their Connecticut home. "It's about taking pleasure in each other's company," she says. For Calais, 41, alcohol is a stress reducer in liquid form. "After a few sips, I definitely feel more relaxed," she says.

Many of us would drink to that. After all, a glass of spirits is not just a quick way to unwind after a stressful day. As a pleasurable part of a good meal, alcohol can also be good for our health, reducing the risk of heart disease and diabetes. The National Center on Addiction and Substance Abuse (CASA), at Columbia University, in New York City, estimates that 47 percent of adult American women and 63 percent of adult American men consume alcohol.

Women's enjoyment of drinking is amply reflected in popular culture. In the HBO series Sex and the City, a cosmopolitan was as much a badge of fabulousness as a pair of Manolo Blahniks. A romantic scene in the 2004 hit film Sideways featured not window-fogging sex but a seductive monologue about wine delivered by a woman. The new hit TV show Grey's Anatomy features a trio of sexy female surgical residents who work hard and drink hard, too. "Must have liquor," declared one as the group prepared to celebrate Thanksgiving. The drinking surge among young women has even gotten marketers working overtime creating new "alcopops," sweet alcoholic drinks such as Bacardi Breezers that are pitched specifically to women.

*Individual's name has been changed at her request.

Women's Greater Risk

But even though drinking has become an equal-opportunity pursuit, it is not an equal-opportunity problem. Women are at significantly greater risk than men for developing serious problems with alcohol and sustaining physical damage from it. Bluntly put, women get drunk and addicted faster and with much less alcohol than men do.

Why the disparity? Pound for pound, women have less water in their bodies than men do, so the alcohol traveling through their bloodstream is less diluted. Women also have lower levels of a stomach enzyme that helps break down alcohol; indeed, for reasons that scientists do not fully understand, female alcoholics often lack this enzyme altogether. "Even if you correct for weight, if you give a man and a woman the same amount of alcohol, the woman will have a higher blood-alcohol level," says Sheila Blume, MD, a former medical director of addiction services at South Oaks Hospital, in Amityville, New York. Because of differences in metabolism, alcohol also lingers longer in a woman's body than in a man's, and a woman will develop liver disease years earlier than a man will, even if she consumes only a fraction of what he ingests.

Metabolic differences may also explain why women who drink heavily tend to become addicted to alcohol more quickly than men do. Estrogen may be implicated, too, says Carrie Randall, PhD, director of the Charleston Alcohol Research Center at the Medical University of South Carolina and author of a study that showed women to be on a faster track to addiction.

Although male alcohol abusers in the United States still vastly outnumber women abusers -- 10 percent of all males (or roughly 12 million men and boys), compared with about 5 percent of all females (6 million women and girls), according to the 2003 National Survey on Drug Use and Health -- that's probably because more men drink. Some experts, in fact, believe the number of women alcoholics may be as high as 7.5 million. And that number is on the rise, reports the National Institute on Alcohol Abuse and Alcoholism (NIAAA).

Yet many women who do not qualify as abusers imbibe more than what is good for them. According to the NIAAA, one in 10 adult women who drink consume more than the recommended one drink per day maximum (defined by the U.S. Department of Health and Human Services as one 5-ounce glass of wine, one 12-ounce bottle of beer or wine cooler, or 1.5 ounces of 80-proof distilled spirits). Moreover, new research suggests that women who drink are increasingly doing so to the point of drunkenness. "There's been a sizable increase in all age groups reporting intoxication," says Sharon Wilsnack, PhD, a clinical psychologist at the University of North Dakota School of Medicine and Health Sciences who has been tracking women's drinking habits for more than two decades.

And drinking begins at ever-younger ages: One 2004 national study found that 23 percent of girls have had their first drink before turning 13. "The gender gap is closing for all ages," says Susan Foster, director of policy research at CASA. "And among eighth- and ninth-graders, there is no difference at all between boys' and girls' drinking behavior."

One fact is crystal clear. Alcohol abuse can place women at serious risk for physical and mental health problems. According to Residence XII, an alcohol-treatment center for women in Kirkland, Washington, women who become addicted to alcohol die 15 years sooner than their counterparts in the general population and have death rates twice as high as male alcoholics. Every year an estimated 21,000 American women die of illnesses and injuries brought on by drinking.

How should you weigh all these grim risks against the growing evidence that moderate drinking (that is, not in excess of the recommended one-drink-a-day maximum) can enhance your health? One study estimates that if all current consumers of alcohol abstained, there would be an additional 80,000 or so deaths each year from coronary heart disease. Moderate drinking may also provide some protection against stroke, adult-onset diabetes, and Alzheimer's disease.

Another study suggests that drinking may even improve cognitive functioning in women in their 70s. Research also shows that women who drink moderately have lower mortality rates than those who do not drink at all.

Does that mean teetotalers should start drinking simply for the health benefits? Not at all, says Denise Russo, PhD, program director at the NIAAA. "Why would someone want to start down that road?" she asks.

Besides, even moderate drinking is not without hazards: There is a curious link between drinking and breast cancer, according to Eric Rimm, ScD, associate professor of epidemiology and nutrition at the Harvard School of Public Health, in Cambridge, Massachusetts. A single drink a day can elevate breast-cancer risk for the average woman with no family history of the disease by as much as 15 percent -- but only in women who don't have enough folate in their diets. Dr. Rimm speculates that alcohol may cause a folate deficiency that is the real source of the breast-cancer link. His Rx: Eat well and take a daily multivitamin.

A Slippery Slope

Kate Levine* would be the first to tell you that she likes to drink. She likes it a lot. "I sort of fixate on it," admits the fortysomething New York City consultant and mother of three. "Nothing relaxes me and makes me feel good like a drink." But she is quick to add, "I don't consider myself an alcoholic." She drinks only on weekends and rarely more than three glasses of wine. "I don't binge, binge, binge until I get drunk," she says. "I drink until I get to that place where I have a buzz going." Although she believes she is firmly on the safe side of the line where drinking shifts from pleasurable to problematic, some experts would argue that she has crossed it.

Levine acknowledges that she looks forward to the weekends, when she allows herself to drink, and that she can't limit herself to just one glass of wine. "These may be red flags," says Sharon Chambers, executive director of Residence XII. "Given the right kind of stress, her drinking could swing out of control."

And given their greater physiological sensitivity to alcohol, women are apt to move more quickly across the continuum from moderate drinking to problem drinking to the addiction of alcoholism. This is especially true for women with a family history of alcohol abuse, who, for unknown reasons, seem to be even more vulnerable to the disease than similar men.

But DNA is not destiny; lifestyle counts, too. You can be hardwired for addiction but won't develop a problem if you don't drink to excess. Nor are you off the hook merely by not being genetically predisposed. "Anyone who drinks enough can become alcohol-dependent," cautions Dr. Blume.

The question, of course, is what is "enough"? At what point does drinking for relaxation veer into problem drinking? Experts agree that you can't put a number on it. Having more than one drink a day doesn't mean a woman has a problem or is developing one. But it increases the odds. "Your body will develop a tolerance to a certain amount of alcohol," notes Stephanie Brown, PhD, director of the Addictions Institute, in Menlo Park, California. To get the desired buzz, you'll need to drink more.

At that point, a two- or three-drink habit may become customary. If a woman's life enters a high-stress zone, she may add another glass or fill the one she already has to the brim. "It's a slippery slope," says Chambers.

Binge drinking -- which is defined as four drinks in one sitting for a woman and five for a man -- can also prime the pump, even if such episodes are rare. (They are increasingly common on college campuses.) According to a 2004 NIAAA report, the risk for alcohol abuse or dependence jumps dramatically for women who exceed three drinks per occasion.

To determine whether her drinking has crossed the line, a woman has to assess the impact that alcohol is having on her life. Is it taking on a more important role? Instead of a movie, for example, does she prefer a party where she can relax with a drink in her hand? Even if there is no physical craving, "this could be the beginning of a psychological preoccupation," says Chambers.

If drinking is causing tangible problems, of course, the signs are inescapable. "Generally, if women experience negative consequences from their drinking -- problems with driving, their job, at home, or with the law -- and continue to drink anyway, that's considered abusive drinking," says Foster.

The line between problem drinking and out-and-out addiction is similarly blurry. In fact, some experts believe there is no line -- that the problem drinker is showing symptoms of addiction, a physical dependency characterized by craving for a drink, a loss of control once drinking, an ever-higher tolerance and withdrawal symptoms when drinking is stopped. "Once a woman is physically dependent, she isn't just drinking for pleasure," observes Dr. Randall. "She's drinking to avoid the withdrawal, the hangover, and the pain."

Levine has not experienced any negative effects from her drinking. But she concedes that "if I drink too much, my husband feels as though I argue with him without provocation in a way I wouldn't otherwise." And her weekends-only rule is flexible. Not long ago she was suffering from pain in her neck and decided to treat it with alcohol, even though it was the middle of the week. She and her husband went to a bar, where she had a shot and a pint of beer. She later drank another beer over pizza. "I got home and fell asleep on the couch," she says. "I felt guilty but the crick in my neck was gone. It was therapeutic."

Like Levine, many women use alcohol to treat their aches and pains, especially emotional ones. "Women more than men drink to self-medicate negative feelings," says Dr. Wilsnack. "That's a fairly common pattern and in my view one of the most important warning signs. Why you drink is as important as how much you drink." (Some experts say that males, by contrast, are more likely to drink out of a sensation-seeking urge.)

The sad irony is that drinking to alleviate depression or to shake off sexual inhibitions -- both common reasons that women reach for the bottle -- can have the opposite effect. "Alcohol is not an antidepressant. If anything, it makes depression worse," says Dr. Blume. And while booze may make a woman feel freer sexually, alcohol decreases sexual pleasure. "The more you drink, the less responsive you are," she says.

*Individual's name has been changed at her request.

A Self-Control Checkup

To ensure that your alcohol consumption is healthy, not hazardous, Dr. Blume advocates reviewing your drinking habits twice a year. "Ask yourself, 'Am I drinking more today than six months ago? Do I ever feel I need a drink? Do I ever not remember things I've said or done when I was drinking? Is drinking creating problems in my life?' If there's any doubt whatsoever, you should seek professional help," she advises.

There is no blood test to diagnose a drinking problem or alcoholism. Addiction experts and counselors rely on probing questions -- and honest answers. Once a problem is identified, there are a number of next steps, depending on the situation (see "Getting Help"). Choices include treatment centers, support groups, and counselors who specialize in addiction.

Regrettably, many women never get the treatment they need. Of the roughly 7 million females who abuse alcohol, only 763,000 receive treatment. That leaves some 6.2 million women without that benefit. Although alcoholic men are likewise undertreated, seeking help can be especially difficult for women, in part because the stigma of alcoholism is so profound. "If you're a woman, there's often shame associated with being out of control of any part of your life," says the NIAAA's Denise Russo.

Women may also face greater obstacles to treatment, from concerns about childcare and custody to financial burdens. And many in treatment feel uncomfortable with mixed-gender groups. At Residence XII, for example, up to 80 percent of the clients have a history of trauma or domestic violence; these women are often loath to discuss an abusive spouse in the presence of men. For that reason, many experts emphasize the importance of women-only treatment programs or meetings. "With all-women programs, there is a different group dynamic than when men are present, and a different group of problems that need to be addressed," says Susan Burnash, director of marketing for Residence XII. Unfortunately, treatment programs tailored to an alcoholic woman's needs can be hard to find. According to CASA, only 38 percent of programs nationwide have options designed for women.

Happily, the vast majority of women who drink will never be in need of such treatment. But the best way to guarantee that is to understand where to draw the line -- and when to pour club soda instead of chardonnay.

Getting Help

If you or a loved one is struggling with alcohol abuse or dependence, it's important to seek help quickly. These national organizations can direct you to local treatment programs and support groups:

Alcoholics Anonymous is one of the oldest and most successful self-help groups for recovering alcoholics. Women make up about 35 percent of the total membership: www.aa.org or 212-870-3400.

Women for Sobriety is the first national self-help program for women alcoholics. For additional information and meeting locations, visit www.womenforsobriety.org or call 215-536-8026. Members also have access to chat rooms and message boards.

The National Council on Alcohol and Drug Dependence has nearly 100 affiliates across the country. The NCADD also offers a National Intervention Network for those seeking advice about a loved one's addiction. Call 800-654-4673 or see www.ncadd.org.

Al-Anon is a 12-step program for friends and relatives of those with an alcohol problem. There's also a group for teens called Alateen: www.al-anon.alateen.org or 888-4AL-ANON.

Substance Abuse and Mental Health Services Administration features a facility locator for treatment services providers across the country at www.samhsa.gov.

Recovery Resources Online is a stand-alone information clearinghouse that operates with support of sponsors and affiliates and includes a directory with hundreds of treatment centers nationwide. Visit www.soberrecovery.com.

 

Addiction Control in a Pill?

Drug therapy alone will not keep an alcoholic on the path to sobriety but it can help. There's a new generation of drugs that, used as part of a recovery program, may work better against alcoholism and be less unpleasant to use than Antabuse, the first drug used to treat alcoholism (see below).

  • Disulfiram (Antabuse), in use since the 1940s, blocks the oxidation of alcohol, heightening sensitivity to it. For someone taking this drug, even small amounts of alcohol will cause a highly unpleasant reaction, including flushing, throbbing in the head and neck, nausea, vomiting, sweating, chest pain, and vertigo. The cost is $38 to $49 per month.
  • Acamprosate (Campral), an anti-craving medication in pill form that received FDA approval in 2004, balances levels of GABA, the brain's major inhibitory neurotransmitter. Experts believe GABA helps curb the urge to seek drugs and other pleasurable experiences. Acamprosate, which costs about $180 per month, can cause gastrointestinal distress as well as headache and confusion.
  • Injectable naltrexone (Vivitrol) is an extended-release formulation of this relatively new oral drug that blocks opiate receptors in the brain, reducing cravings in some alcoholics. Because it is delivered as a monthly shot rather than a daily pill, the hope is that Vivitrol will improve compliance. FDA approval may come this year. Naltrexone can cause gastrointestinal distress and headaches. The oral drug starts around $137 per month; the price for the injectable version is not yet established.
  • Topiramate (Topamax) is a high-powered drug in pill form that is an FDA-approved treatment for epilepsy and migraines. New research suggests that it is the most promising alcoholism treatment in the research pipeline, according to Nassima Ait-Daoud, MD, director of the Center for Addiction Research and Education at the University of Virginia, in Charlottesville, who was involved in the testing. By blocking the release of the neurotransmitter dopamine, topiramate kills the craving for alcohol and blocks withdrawal symptoms. And unlike Antabuse, topiramate doesn't make you sick if you drink, which may encourage more people to start treatment. Multisite trials are under way, and FDA approval may be granted by the end of this year. It will cost about $300 per month.

Originally published in Ladies' Home Journal, May 2006.

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