Alcohol Abuse and Dependence

- Behavioral issues - Anxiety, depression, insomnia - Psychological and social dysfunction, marital problems - Social isolation/withdrawal - Domestic violence - Alcohol-related legal problems - Repeated attempts to stop/reduce - Loss of interest in nondrinking activities - Employment problems (tardiness, absenteeism, decreased productivity, interpersonal problems, frequent job loss) - Blackouts - Complaints about alcohol-related behavior - Frequent trauma, MVAs, ED visits

- CBC; liver function tests (LFTs); electrolytes; BUN/creatinine; lipid panel; thiamine; folate; hepatitis A, B, and C serology - Amylase, lipase (if GI symptoms present) - Serum levels increased in chronic abuse: - AST/ALT ratio >2.0 - Ī³-glutamyl transferase (GGT) - Carbohydrate-deficient transferrin - Elevated mean corpuscular volume (MCV) - ā†‘ Prothrombin time - Uric acid - ā†‘Triglycerides and cholesterol (total)

- Contraindications - Naltrexone: pregnancy, acute hepatitis, hepatic failure - Monitor LFTs.

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Common and underdiagnosed in elderly; less likely to report problem; may exacerbate normal age-related cognitive deficits and disabilities
Multiple drug interactions
Signs and symptoms may be different or attributed to chronic medical problem or dementia.
Common assessment tools may be inappropriate.

Pediatric Considerations

Children of alcoholics are at increased risk.
In 2004, 28% of persons 12 to 20 years reported use in past month, one in five binge drink; binge drinkers are seven times more likely to report illicit drug use.
Negative effect on maturation and development
Early drinkers are four times more likely to develop a problem than those who begin >21 years.
Depression, suicidal or disorderly behavior, family disruption, violence or destruction of property, poor school or work performance, sexual promiscuity, social immaturity, lack of interests, isolation, moodiness

Pregnancy Considerations

Alcohol is teratogenic, especially during the 1st trimester; women should abstain during conception and throughout pregnancy.
10-50% of children born to women who are heavy drinkers will have fetal alcohol syndrome.
Women experience harmful effects at lower levels and are less likely to report problems.

EPIDEMIOLOGY

Predominant age: 18 to 25 years, but all ages affected
Predominant sex: male > female (3:1)

Prevalence

Lifetime prevalence: 13.6%
20% in primary care setting
48.2% of 21-year-olds in the United States reported binge drinking in 2004.

ETIOLOGY AND PATHOPHYSIOLOGY

Multifactorial: genetic, environment, psychosocial

Alcohol is a CNS depressant, facilitating Ī³-aminobutyric acid (GABA) inhibition and blocking N-methyl-d-aspartate receptors.

Genetics

50-60% of risk is genetic.

RISK FACTORS

Family history
Depression (40% with comorbid alcohol abuse)
Anxiety
Other substance abuse
Tobacco
Male gender
Low socioeconomic status
Unemployment
Peer/social approval
Family dysfunction or childhood trauma
Posttraumatic stress disorder
Antisocial personality disorder
Bipolar disorder
Eating disorders
Criminal involvement

GENERAL PREVENTION

Counsel with family history and risk factors

COMMONLY ASSOCIATED CONDITIONS

Cardiomyopathy, atrial fibrillation
Hypertension
Peptic ulcer disease/gastritis
Cirrhosis, fatty liver, cholelithiasis
Hepatitis
Diabetes mellitus
Pancreatitis
Malnutrition
Upper GI malignancies
Peripheral neuropathy, seizures
Abuse and violence
Trauma (falls, motor vehicle accidents [MVAs])
Severe psychiatric disorders (depression, bipolar, schizophrenia): >50% of patients with these disorders have a comorbid substance abuse problem.

DIAGNOSIS

HISTORY

Behavioral issuesAnxiety, depression, insomniaPsychological and social dysfunction, marital problemsSocial isolation/withdrawalDomestic violenceAlcohol-related legal problemsRepeated attempts to stop/reduceLoss of interest in nondrinking activitiesEmployment problems (tardiness, absenteeism, decreased productivity, interpersonal problems, frequent job loss)BlackoutsComplaints about alcohol-related behaviorFrequent trauma, MVAs, ED visits
Physical symptomsAnorexiaNausea, vomiting, abdominal painPalpitationsHeadacheImpotenceMenstrual irregularitiesInfertility

PHYSICAL EXAM

Physical exam may be completely normal.
General: fever, agitation, diaphoresis
Head/eyes/ears/nose/throat: plethoric face, rhinophyma, poor oral hygiene, oropharyngeal malignancies
Cardiovascular: hypertension, dilated cardiomyopathy, tachycardia, arrhythmias
Respiratory: aspiration pneumonia
GI: stigmata of chronic liver disease, peptic ulcer disease, pancreatitis, esophageal malignancies, esophageal varices
Genitourinary: testicular atrophy
Musculoskeletal: poorly healed fractures, myopathy, osteopenia, osteoporosis, bone marrow suppression
Neurologic: tremors, cognitive deficits (e.g., memory impairment), peripheral neuropathy, Wernicke-Korsakoff syndrome
Endocrine/metabolic: hyperlipidemias, cushingoid appearance, gynecomastia
Dermatologic: burns (e.g., cigarettes), bruises, poor hygiene, palmar erythema, spider telangiectasias, caput medusae, jaundice

DIFFERENTIAL DIAGNOSIS

Other substance use disorders
Depression
Dementia
Cerebellar ataxia
Cerebrovascular accident (CVA)
Benign essential tremor
Seizure disorder
Hypoglycemia
Diabetic ketoacidosis
Viral hepatitis

DIAGNOSTIC TESTS & INTERPRETATION

Screening:

CAGE Questionnaire: (Cut down, Annoyed, Guilty, and Eye opener): >2 "yes"¯ answers is 74-89% sensitive, 79-95% specific for alcohol use disorder; less sensitive for white women, college students, elderly. Not an appropriate tool for less severe forms of alcohol abuse (1)[A]
Single question for unhealthy use: "How many times in the last year have you had X or more drinks in 1 day?"¯ (X = 5 for men, 4 for women); 81.8% sensitive, 79% specific for alcohol use disorders (2)[C]
Alcohol Use Disorders Identification Test (AUDIT): 10 items, if >4: 70-92% sensitive, better in populations with low incidence of alcoholism (3)[A]: http://www.nams.sg/addictions/Alcohol/Pages/Self-Assessment-Tool.aspx

Initial Tests (lab, imaging)

CBC; liver function tests (LFTs); electrolytes; BUN/creatinine; lipid panel; thiamine; folate; hepatitis A, B, and C serology
Amylase, lipase (if GI symptoms present)
Serum levels increased in chronic abuse:AST/ALT ratio >2.0Ī³-glutamyl transferase (GGT)Carbohydrate-deficient transferrinElevated mean corpuscular volume (MCV)ā†‘ Prothrombin timeUric acidā†‘Triglycerides and cholesterol (total)
Often decreasedCalcium, magnesium, potassium, phosphorusBUNHemoglobin, hematocritPlatelet countSerum protein, albuminThiamine, folate
Blood alcohol concentration>100 mg/dL in outpatient setting>150 mg/dL without obvious signs of intoxication>300 mg/dL at any time
CAT scan or MRI of brain: cortical atrophy, lesions in thalamic nucleus, and basal forebrain
Abdominal ultrasound (US): ascites, periportal fibrosis, fatty infiltration, inflammation

Test Interpretation

Liver: inflammation or fatty infiltration (alcoholic hepatitis), periportal fibrosis (alcoholic cirrhosis occurs in only 10-20% of alcoholics)
Gastric mucosa: inflammation, ulceration
Pancreas: inflammation, liquefaction necrosis
Heart: dilated cardiomyopathy
Immune system: decreased granulocytes
Endocrine organs: elevated cortisol levels, testicular atrophy, decreased female hormones
Brain: cortical atrophy, enlarged ventricles

TREATMENT

For management of acute withdrawal, please see "Alcohol Withdrawal."¯
For outpatient withdrawal treatment, see "Alcohol Withdrawal, Treatment"¯ or http://www.aafp.org/afp/2005/0201/p495.html

GENERAL MEASURES

Brief interventions and counseling by clinicians have proven efficacy for problem drinking (4)[B].
Treat comorbid problems (sleep, anxiety, etc.); but do not prescribe medications with cross tolerance to alcohol (benzodiazepine).
Group programs and/or 12-step programs may have benefit in helping patients accept treatment.
Research shows the benefit of referring patients with alcohol dependence to an addiction specialist or treatment program (3)[A].

MEDICATION

First Line

Adjuncts to withdrawal regimens:Naltrexone: 50 to 100 mg/day PO or 380 mg IM once every 4 weeks; opiate antagonist reduces craving and likelihood of relapse, decreases number of heavy drinking days in recalcitrant alcohol abusers (IM route may enhance compliance and thus efficacy) (3,5)[A].Acamprosate (Campral): 666 mg PO TID beginning after completion of withdrawal; reduces relapse risk. If helpful, recommended to use for 1 year (6)[A].Topiramate (Topamax): 25 to 300 mg/day PO or divided BID; enhances abstinence (3,5)[B] (not approved by FDA for use in alcohol dependence; off-label use)
Supplements to allThiamine: 100 mg/day (1st dose IV prior to glucose to avoid Wernicke encephalopathy)Folic acid: 1 mg/dayMultivitamin: daily
ContraindicationsNaltrexone: pregnancy, acute hepatitis, hepatic failureMonitor LFTs.
Precautions: organic pain, organic brain syndromes
Significant possible interactions: alcohol, sedatives, hypnotics, naltrexone, and narcotics

ALERT

Treat acute symptoms if in alcohol withdrawal; give thiamine 100 mg/day with 1st dose prior to glucose.

Second Line

Disulfiram: 250 to 500 mg/day PO; unproven efficacy; may provide psychological deterrent. Most effective if used with close supervision (5)[A]
Selective serotonin reuptake inhibitors may be beneficial if comorbid depression exists (5)[A].

ISSUES FOR REFERRAL

Addiction specialist, 12-step or long-term program, psychiatrist

INPATIENT CONSIDERATIONS

Assess medical and psychiatric condition (CIWA >8).

Admission Criteria/Initial Stabilization

Correct electrolyte imbalances, acidosis, hypovolemia (treat if in alcohol withdrawal).
Thiamine: 100 mg IM, followed by 100 mg PO; folic acid: 1 mg/day
Benzodiazepines used to lower risk of alcohol withdrawal, seizures

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Patient Monitoring

Outpatient detoxification: daily visits (not recommended for heavy alcohol abuse)
Early outpatient rehabilitation: weekly visits
Detoxification alone is not sufficient.

PATIENT EDUCATION

American Council on Alcoholism: (800) 527-5344 or http://www.aca-usa.com/ (treatment facility locator, educational information)
National Clearinghouse for Alcohol and Drug Information: (800) 729-6686 or http://www.health.org/
Center for Substance Abuse Treatment: (800) 662-HELP or http://www.samhsa.gov/about-us/who-we-are/offices-centers/csat
Alcoholics Anonymous: http://www.aa.org/
Rational Recovery: https://rational.org/index.php?id=1
Secular Organizations for Sobriety: http://www.centerforinquiry.net/sos
http://www.alcoholanswers.org/: An evidence-based website for those seeking credible information on alcohol dependence and online support forums.

PROGNOSIS

Chronic relapsing disease; mortality rate more than twice general population, death 10 to 15 years earlier
Abstinence benefits survival, mental health, family, employment
12-step programs, cognitive behavior, and motivational therapies are often effective during 1st year following treatment.

COMPLICATIONS

Cirrhosis (women sooner than men)
GI malignancies
Neuropathy, dementia, Wernicke-Korsakoff syndrome
CVA
Ketoacidosis
Infection
Adult respiratory distress syndrome
Depression
Suicide
Trauma

REFERENCES

11 Dhalla S, Kopec JA. The CAGE questionnaire for alcohol misuse: a review of reliability and validity studies. Clin Invest Med. 2007;30(1):33-41.22 Smith PC, Schmidt SM, Allensworth-Davies D, et al. Primary care validation of a single-question alcohol screening test. J Gen Intern Med. 2009;24(7):783-788.33 Willenbring ML, Massey SH, Gardner MB. Helping patients who drink too much: an evidence-based guide for primary care clinicians. Am Fam Physician. 2009;80(1):44-50.44 McQueen J, Howe TE, Allan L, et al. Brief interventions for heavy alcohol users admitted to general hospital wards. Cochrane Database Syst Rev. 2011;(8):CD005191.55 Miller PM, Book SW, Stewart SH. Medical treatment of alcohol dependence: a systematic review. Int J Psychiatry Med. 2011;42(3):227-266.66 R ¶sner S, Hackl-Herrwerth A, Leucht S, et al. Acamprosate for alcohol dependence. Cochrane Database Syst Rev. 2010;(9):CD004332.

ADDITIONAL READING

National Institute on Alcohol Abuse and Alcoholism. Helping patients who drink too much: a clinician's guide. http://www.niaaa.nih.gov/guide.

CODES

ICD10

F10.10 Alcohol abuse, uncomplicated
F10.20 Alcohol dependence, uncomplicated
F10.239 Alcohol dependence with withdrawal, unspecified
F10.288Alcohol dependence with other alcohol-induced disorder
F10.229Alcohol dependence with intoxication, unspecified
F10.99Alcohol use, unsp with unspecified alcohol-induced disorder

ICD9

305.00Alcohol abuse, unspecified
303.90Other and unspecified alcohol dependence, unspecified
291.81Alcohol withdrawal
305.01Alcohol abuse, continuous
305.03Alcohol abuse, in remission
305.02Alcohol abuse, episodic
303.91Other and unspecified alcohol dependence, continuous
303.93Other and unspecified alcohol dependence, in remission
303.92Other and unspecified alcohol dependence, episodic

SNOMED

15167005Alcohol abuse (disorder)
66590003Alcohol dependence (disorder)
191480000Alcohol withdrawal syndrome (disorder)
7200002Alcoholism (disorder)
284591009persistent alcohol abuse (disorder)

CLINICAL PEARLS

CAGE Questionnaire: >2 "yes"¯ answers is 74-89% sensitive, 79-95% specific for alcohol use disorder; less sensitive for white women, college students, elderly. Not an appropriate tool for less severe forms of alcohol abuse
Single question for unhealthy use screening: "How many times in the last year have you had X or more drinks in 1 day?"¯ (X = 5 for men, 4 for women); 81.8% sensitive, 79% specific for alcohol use disorders
National Institute on Alcohol Abuse and Alcoholism criteria for "at-risk"¯ drinking: men >14 drinks a week or >4 per occasion; women: >7 drinks a week or >3 per occasion