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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 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
- Physical symptoms
- Anorexia
- Nausea, vomiting, abdominal pain
- Palpitations
- Headache
- Impotence
- Menstrual irregularities
- Infertility
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 >2.0
- Ī³-glutamyl transferase (GGT)
- Carbohydrate-deficient transferrin
- Elevated mean corpuscular volume (MCV)
- ā†‘ Prothrombin time
- Uric acid
- ā†‘Triglycerides and cholesterol (total)
- Often decreased
- Calcium, magnesium, potassium, phosphorus
- BUN
- Hemoglobin, hematocrit
- Platelet count
- Serum protein, albumin
- Thiamine, 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 all
- Thiamine: 100 mg/day (1st dose IV prior to glucose to avoid Wernicke encephalopathy)
- Folic acid: 1 mg/day
- Multivitamin: daily
- Contraindications
- Naltrexone: pregnancy, acute hepatitis, hepatic failure
- Monitor 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.
SEE ALSO
Substance Use Disorders; Alcohol Withdrawal
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