The Stages of Alcoholism and How To Know When You Have a Problem
This article was originally published on WebMD Connect to Care
Alcoholism, or alcohol use disorder (AUD), doesn’t develop overnight. Knowing the stages of AUD could be key to prevention and treatment.
“Early signs of problem drinking or alcohol misuse can be subtle. For example, starting to prioritize activities that involve alcohol steadily leads to a shift in daily routines and relationships,” Dr. Harshal Kirane, Medical Director of Wellbridge treatment centers in New York, tells WebMD Connect to Care. “As drinking becomes more routine, changes in sleep patterns, mood, energy, and interests can signal the onset of early alcohol use disorder.”
What is alcoholism?
Alcoholism is a physical and psychological dependency on alcohol that also interferes with daily life. Symptoms of alcoholism include an intense urge to drink and a loss of control when drinking alcohol. Advanced alcoholism can include drinking to avoid withdrawal symptoms like the shakes and nausea. According to the National Institutes for Health, about 14 million American adults struggle with AUD.
“To clarify terminology: Alcohol dependence is diagnosed using criteria outlined in DSM-IV, the handbook used by healthcare providers to diagnose brain disorders. More recently, with the release of DSM-5, healthcare providers have started using the term alcohol use disorder (AUD).” explains Dr. Joseph Volpicelli, Executive Director at Institute of Addiction Medicine in Pennsylvania.
The 5 stages of alcoholism
Alcohol use disorder is progressive and takes time to develop. Here are some indicators of each phase:
Pre-Alcoholic: In the pre-alcoholic stage, a person begins to drink to relieve stress. During this stage tolerance can start increasing, meaning more alcohol is needed to get the same effect. “ First, there is a period in which alcohol use has crossed the line from recreational use to addiction. This occurs when drinking creates the need for more drinking.” explains Dr. Volpicelli.
Early Alcoholic: During the early alcoholic phase, alcohol can begin to affect a person’s relationships, job and daily life. These disruptions can lead to guilt and shame, which can lead to drinking even more. “For some, this is a critical tipping point, because alcohol intake increases in an attempt to alleviate the very challenges it is creating,” Dr. Kirane says.
Middle Alcoholic: During this phase, drinking becomes more frequent, and the person might try to hide or rationalize their drinking. They might also try to quit, only to start again. “One of the hallmarks of AUD is continuing to drink despite experiencing physical consequences from drinking.” says Dr. Adam D. Scioli, Medical Director and Head of Psychiatry at Caron Treatment Centers.
Late Alcoholic: At this point, the individual can no longer control their drinking. They might also exhibit physical symptoms of prolonged alcohol abuse and suffer from withdrawal when trying to stop drinking. Withdrawal occurs when abstaining from alcohol leads to physical symptoms like shaking, nausea and in more extreme cases, seizures, and tremors.
Recovery: The recovery phase is when the individual gets help. This will sometimes involve hitting a “rock bottom”, but you don’t have to have significant consequences to get help and stop drinking. There is a popular saying in the sober community: “Rock bottom is where you stop digging.”
Do you have to hit rock bottom to quit drinking?
“The idea that someone has to hit “rock bottom” is a fallacy that delays early intervention and promotes stigma.” explains Dr. Scioli. “Everyone's ‘bottom’ or realization they need help is different. For some, it may be that they’ve experienced a negative consequence – they’re facing a divorce or job loss. For others it could be they just don’t like the way they feel or they see their children pretend to drink from an empty bottle. The fact is: the earlier an AUD is addressed, the better the outcome.”
It’s also important to know that the above stages are not uniform, and might not apply to everyone with AUD. “The ‘stage’ framework of alcohol use disorder (AUD) is intuitive, but doesn’t always match people’s lived experience.” explains Dr. Audrey Klein, psychologist at Mindstrong. “This framework assumes that people who develop alcohol problems go through a set number of stages in a certain order. It is more accurate to describe AUD in terms of severity rather than stages.”
“The level of AUD severity is determined by experiences with these symptoms. People with mild AUD have 2-3 symptoms, those with moderate AUD have 4-5 symptoms, and those with severe AUD have 6 or more symptoms. In most cases problematic alcohol use is progressive - people drink more heavily and more often over time. Problems associated with drinking increase as well. The time course of the progression differs across individuals. Some drink at moderate levels for years before developing problems. Others move more quickly into severe AUD once they begin drinking.” continues Dr. Klein.
According to a 2022 study published in Addictive Behaviors, a main barrier to treatment is problem recognition. However, promoting the idea that AUD exists as a spectrum may help with self-recognition of problematic drinking.
As Dr. Scioli and Dr. Klein explained, it can be problematic to subscribe to the idea that you must meet certain accepted criteria (like a rock bottom moment or drinking in the morning) in order to have a problem with alcohol. This misconception can prevent many individuals from recognizing the need to address their alcohol use when early intervention could still be possible.
What is the first step in treating alcohol use disorder?
Treatment often begins with detoxing from alcohol, and experts recommend doing this under medical supervision for safety. According to Mayo Clinic, treatment may involve speaking to your primary care provider, getting counseling or attending inpatient or outpatient programs. A doctor can prescribe medication to assist you with quitting drinking, like Antabuse or Naltrexone, and counseling can help you to learn new skills to cope with stress, anxiety or depression.
“There are numerous ways to get help, but it starts by reaching out. Reach out to a friend or family you trust can support you non-judgmentally,” Dr. Kirane says. “If that is hard to identify: 12-step groups, SMART recovery, or online forums can be less threatening outlets.”
Alcohol Treatment and Recovery
For those earlier in the progression towards addiction, recognizing the cycle of drinking and negative consequences can be helpful in getting the person out of the loop and into recovery.
“At this stage, these harmful consequences may not be evident to the person who is drinking, and the person is not thinking about getting treatment.” explains Dr. Volpicelli. “This is the stage where public health efforts can help draw attention to the health consequences of drinking and begin to ‘connect the dots’ for the person that drinking is the reason when they feel increasingly irritable, why friends have stopped calling, why they were passed over for a promotion. Health care professionals have an important role in assessing for alcohol addiction by checking for biological markers of excessive drinking or liver damage.”
For those later in the progression towards addiction, detoxing alone can be dangerous and it is recommended to detox under medical supervision. After detox, the treatment depends on the individual’s needs and any comorbidities that are present, like depression, anxiety or trauma.
“The course of AUD varies for each individual.” explains Dr. Klein. “In general, the most effective treatments don’t target a given stage of AUD. Instead, healthcare providers assess the nature and extent of the problems in each patient. Treatment then addresses these areas.”
If there are any medical consequences from heavy drinking, like liver damage, then these issues need to be addressed by a doctor. It is important for the individual to learn coping skills and work on the reasons why they drank.
There are also a variety of medications that can assist in maintaining recovery. “In my practice, we routinely use extended-release naltrexone or Vivitrol as a once-a-month injection to help prevent relapse.” says Dr. Volpicelli.
“We find that Vivitrol reduces alcohol craving, and should a person have an alcohol slip, the medicine helps keep the slip from becoming a relapse. We also routinely use psychiatric medicines to treat underlying anxiety and depression. The medications are part of our program that includes psychosocial support to help maintain patients’ motivation to stay in treatment and to address any underlying issues,” Volpicelli says.
Can you fully recover from being an alcoholic?
“AUD is a chronic disease, much like diabetes, that must be carefully managed.” explains Dr. Scioli. “There is no ‘cure’ for AUD, so recovery from AUD requires continued vigilance and commitment. You have to do the work, as the saying goes. That said, long-term recovery is possible. 75% of those with a substance use disorder will eventually enter recovery over the course of their lives.”
“People who self-identify as being in recovery often describe it as a process of positive development and growth.” A study published in the Journals of Studies on Alcohol and Drugs “asked people what recovery means to them, many discussed self-honesty, handling negative feelings without drinking, being able to enjoy life without drinking, reacting to life experiences in a more balanced way, and taking responsibility for the things you can change or control.”
To be in remission from AUD, the DSM-5 “requires that the individual not meet any AUD criteria (excluding craving).” Remission is broken down into a few stages:
Initial: up to 3 months
Early: 3 months to 1 year
Sustained: 1 to 5 years
Stable: more than 5 years
According to the NIAAA, recovery is an ongoing process that involves the fulfillment of basic needs, enhancements in social support, and improvements in physical and mental health, quality of life, and general wellbeing.
For some, recovery can be a lifelong pursuit. “It’s about trying to be better and do better than you did yesterday, and not giving up on that goal.” shares Dr. Klein.
Sources:
1. Hazelden Betty Ford Foundation. Stages of Alcoholism. 2019
2. Mayo Clinic. Alcohol Use Disorder.
3. Hagman, B. et al. Defining Recovery From Alcohol Use Disorder: Development of an NIAAA Research Definition. The American Journal of Psychiatry. 2022.
4. Leonhard, A. et al. The effect of alcohol use disorder symptom and recovery narratives on problem-recognition: A randomized online trial. Addictive Behaviors. 2022.
