ONSET AND CLINICAL COURSE
Much research on substance use has focused on alcohol because it is legal and more widely used; thus, more is known about alcohol’s effects. The prognosis for alcohol use in general is unclear because usually only people seek-ing treatment for problems with alcohol are studied.
The early course of alcoholism typically begins with the first episode of intoxication between 15 and 17 years of age (Schuckit, 2005); the first evidence of minor alcohol-related problems is seen in the late teens. These events do not differ significantly from the experiences of people who do not go on to develop alcoholism. A pattern of more severe difficulties for people with alcoholism begins to emerge in the mid-twenties to the mid-thirties; these dif-ficulties can be the alcohol-related breakup of a significant relationship, an arrest for public intoxication or driving while intoxicated, evidence of alcohol withdrawal, early alcohol-related health problems, or significant interference with functioning at work or school. During this time, the person experiences his or her first blackout, which is an episode during which the person continues to function but has no conscious awareness of his or her behavior at the time or any later memory of the behavior.
As the person continues to drink, he or she often devel-ops a tolerance for alcohol; that is, he or she needs more alcohol to produce the same effect. After continued heavy drinking, the person experiences a tolerance break, which means that very small amounts of alcohol intoxicate the person.
The later course of alcoholism, when the person’s func-tioning definitely is affected, is often characterized by peri-ods of abstinence or temporarily controlled drinking. Abstinence may occur after some legal, social, or interper-sonal crisis, and the person may then set up rules about drinking such as drinking only at certain times or drinking only beer. This period of temporarily controlled drinking soon leads to an escalation of alcohol intake, more prob-lems, and a subsequent crisis. The cycle repeats continu-ously (Schuckit, 2005).
For many people, substance use is a chronic illness characterized by remissions and relapses to former levels of use (Jaffe & Anthony, 2005). The highest rates for suc-cessful recovery are for people who abstain from sub-stances, are highly motivated to quit, and have a past history of life success (i.e., satisfactory experiences in cop-ing, work, relationships, etc.). Although an estimated 60% to 70% of people in alcoholism treatment remain sober after 1 year (Schuckit, 2005), this estimate may be optimistic—and misleading—because most relapses occur during the second year after treatment.
Evidence shows that some people with alcohol-related problems can modify or quit drinking on their own with-out a treatment program; this is called spontaneous remis-sion or natural recovery (Bischof, Rumpf, Meyer, Hapke, John, 2007). The abstinence was often in response to a crisis or a promise to a loved one and was accomplished by engaging in alternative activities, relying on relationships with family and friends, and avoiding alcohol, alcohol users, and social cues associated with drinking. Spontane-ous remission can occur in as many as 20% of alcoholics, although it is highly unlikely that people in the late stage of alcoholism can recover without treatment (Schuckit, 2005).
Poor outcomes have been associated with an earlier age at onset, longer periods of substance use, and the coexis-tence of a major psychiatric illness. With extended use, the risk for mental and physical deterioration and infectious disease such as HIV and AIDS, hepatitis, and tuberculosis increases, especially for those with a history of intravenous drug use. In addition, people addicted to alcohol and drugs have a rate of suicide 20% higher than that of the general population.