Alcohol dependence

Epidemiology of drinking

In 2012, 51.3% of adults 18 years of age and over in the United States were current regular drinkers (at least 12 drinks in the past year) and 12.9% were current infrequent drinkers (1-11 drinks in the past year): 12.9%

There are approximately 88,000 deaths attributable to excessive alcohol use each year in the United States. Excessive alcohol use is the 3rd leading lifestyle-related cause of death for the Americans; responsible for 2.5 million years of potential life lost (YPLL) annually, or an average of about 30 years of potential life lost for each death. The economic costs of excessive alcohol consumption in 2006 were estimated at $223.5 billion.

It is estimated that only 10% to 20% of patients undergoing alcohol withdrawal are treated as inpatients, so it is possible that as many as 2 million Americans may experience symptoms of alcohol withdrawal conditions each year.

Categories of alcohol use:

  1. No use
  2. Low risk use
  3. Hazardous drinking
  4. Alcohol abuse
  5. Alcohol dependence

Health risks related to drinking

Short-Term Health Risks

Excessive alcohol use has immediate effects that are most often the result of binge drinking and include the following:

  • Injuries: (Smith 1999)
    • Traffic injuries
    • Falls
    • Drowning
    • Burns
    • Unintentional firearm injuries
  • Violence:
    • Intimate partner violence and
    • Child maltreatment.
    • About 35% of victims report that offenders are under the influence of alcohol. (Greenfield 1998)
    • Alcohol use is also associated with 2 out of 3 incidents of intimate partner violence. (Greenfield 1998)
    • Studies have also shown that alcohol is a leading factor in child maltreatment and neglect cases, and is the most frequent substance abused among these parents.
  • Risky sexual behaviors
    • Unprotected sex,
    • Sex with multiple partners
    • Increased risk of sexual assault
    • These behaviors can result in unintended pregnancy or sexually transmitted diseases (Naimi et al 2003; Wechsler et al 1994)
  • Miscarriage and stillbirth among pregnant women, and a combination of physical and mental birth defects among children that last throughout life. (Kesmodel 2002)
  • Alcohol poisoning, a medical emergency that can cause loss of consciousness, low blood pressure and body temperature, coma, respiratory depression, or death. (Sanap 2003)

Long-Term Health Risks

  • Long-term excessive alcohol use can lead to the development of chronic diseases, neurological impairments and social problems such as:
    • Neurological
      • Dementia
      • Stroke
      • Neuropathy
    • Cardiovascular problems
      • Myocardial infarction
      • Cardiomyopathy
      • Atrial fibrillation
      • Hypertension
    • Psychiatric problems
      • Depression
      • Anxiety
      • Suicide
    • Social problems
      • Unemployment
      • Lost productivity
      • Family problems
    • Cancers of:
      • Mouth, throat, esophagus, pancreas, stomach, liver, colon, and breast
    • Liver diseases, including:
      • Alcoholic hepatitis.
      • Cirrhosis, which is among the 15 leading causes of all deaths in the United States (Heron 2007)

Alcohol receptors

  • The brain maintains neurochemical balance through inhibitory and excitatory neurotransmitters.
  • The main inhibitory neurotransmitter is γ-amino-butyric acid (GABA), which acts through the GABA-alpha (GABA-A) neuroreceptor.
  • One of the major excitatory neurotransmitters is glutamate, which acts through the N-methyl-D-aspartate (NMDA) neuroreceptor.
  • Alcohol enhances the effect of GABA on GABA-A neuroreceptors, resulting in decreased overall brain excitability.
  • Chronic exposure to alcohol results in a compensatory decrease of GABA-A neuroreceptor response to GABA, evidenced by increasing tolerance of the effects of alcohol.
  • Alcohol inhibits NMDA neuroreceptors, and chronic alcohol exposure results in up-regulation of these receptors. Abrupt cessation of alcohol exposure results in brain hyperexcitability, because receptors previously inhibited by alcohol are no longer inhibited. Brain hyperexcitability manifests clinically as anxiety, irritability, agitation, and tremors. Severe manifestations include alcohol withdrawal seizures and delirium tremens.
  • Kindling:
    • An important concept in both alcohol craving and alcohol withdrawal is the “kindling” phenomenon;
    • the term refers to long-term changes that occur in neurons after repeated detoxifications.
    • Recurrent detoxifications are postulated to increase obsessive thoughts or alcohol craving.5
    • Kindling explains the observation that subsequent episodes of alcohol withdrawal tend to progressively worsen.
    • Although the significance of kindling in alcohol withdrawal is debated, this phenomenon may be important in the selection of medications to treat withdrawal.
    • If certain medications decrease the kindling effect, they may become preferred agents.

Diagnostic Criteria for Alcohol Withdrawal (DSM-IV)

  •  Two (or more) of the following, developing within several hours to a few days after following criterion:
    • Autonomic hyperactivity (e.g., sweating or pulse rate greater than 100 beats per minute)
    • Increased hand tremor
    • Insomnia
    • Nausea or vomiting
    • Transient visual, tactile, or auditory hallucination s or illusions
    • Psychomotor agitation
    • Anxiety
    • Grand mal seizures
  • The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning and the symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

Alcohol withdrawal symptoms

  • Generally, the symptoms of alcohol withdrawal relate proportionately to the amount of alcoholic intake and the duration of a patient’s recent drinking habit.
  • Minor withdrawal symptoms can occur while the patient still has a measurable blood alcohol level. These symptoms may include insomnia, mild anxiety, and tremulousness.
  • Patients with alcoholic hallucinosis experience visual, auditory, or tactile hallucinations but otherwise have a clear sensorium.
  • Seizures: Withdrawal seizures are more common in patients who have a history of multiple episodes of detoxification. Causes other than alcohol withdrawal should be considered if seizures are focal, if there is no definite history of recent abstinence from drinking, if seizures occur more than 48 hours after the patient’s last drink, or if the patient has a history of fever or trauma.
  • Delirium tremens: Alcohol withdrawal delirium, or delirium tremens, is characterized by clouding of consciousness and delirium. Episodes of delirium tremens have a mortality rate of 1% to 5%. (Kasser 2004) Risk factors for developing alcohol withdrawal delirium include concurrent acute medical illness, daily heavy alcohol use, history of delirium tremens or withdrawal seizures, older age, abnormal liver function, and more severe withdrawal symptoms on presentation.
  • Symptoms of Alcohol Withdrawal Syndrome
    • Minor withdrawal symptoms (6 to 12 hours):
      • insomnia,
      • tremulousness,
      • mild anxiety
      • gastrointestinal upset,
      • headache
      • diaphoresis
      • palpitations
      • anorexia
    • Alcoholic hallucinosis (12 to 24 hours):
      • visual, auditory, or tactile hallucinations
      • Symptoms generally resolve within 48 hours.
    • Withdrawal seizures (24 to 48 hours):
      • generalized tonic-clonic seizures
      • Symptoms reported as early as two hours after cessation.
    • Alcohol withdrawal delirium (delirium tremens) (48 to 72 hours):
      • hallucinations (predominately visual),
      • disorientation,
      • tachycardia,
      • hypertension,
      • low-grade fever,
      • agitation,
      • diaphoresis
      • Symptoms peak at five days.

Patient assessment

  1. Quantity of daily alcoholic intake
  2. Duration of alcohol use
  3. Frequency of use
  4. Type of drinks
  5. Time since last drink,
  6. Previous alcohol withdrawals,
  7. Presence of concurrent medical or psychiatric conditions, and
  8. Abuse of other agents
  9. Reason for dinking
  10. CAGE
    1. Cut down
    2. Annoyed
    3. Guilty
    4. Eye-opener
  11. Drink to get high
  12. Drinking alone
  13. Tolerance
  14. Black outs
  15. Intoxications
  16. Seizure
  17. Family history of alcoholism
  18. Medical problems related to drinking:
    1. Liver diseases
    2. Pancreatitis
    3. Esophageal cancer
    4. Cardiomyopathy
    5. Double vision
    6. Gait imbalance
    7. Poor memory
    8. Anemia
    9. Coagulopathy
    10. Wernicke’s-Korsakoff’s encephalopathy

Physical examination

  1. Blood pressure
  2. Pulse rate
  3. Cardiac exam for: Tachycardia, Arrhythmias, congestive heart failure, coronary artery disease
  4. Gastrointestinal bleeding
  5. Signs of liver disease and cirrhosis
  6. Neuropathy
  7. Pancreatitis
  8. CIWA: The revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale is a validated 10-item assessment tool that can be used to quantify the severity of alcohol withdrawal syndrome, and to monitor and medicate patients going through withdrawal
    1. CIWA-Ar scores of 8 points or fewer correspond to mild withdrawal,
    2. scores of 9 to 15 points correspond to moderate withdrawal, and
    3. Scores of greater than 15 points correspond to severe withdrawal symptoms and an increased risk of delirium tremens and seizures.
  9. In using the CIWA-Ar, the clinical picture should be considered because medical and psychiatric conditions may mimic alcohol withdrawal symptoms.
  10. Certain medications (e.g., beta blockers) may blunt the manifestation of these symptoms.

Laboratory work up

  1. CBC, diff
  2. Liver function test
  3. Urine drug screen
  4. Electrolyte levels
  5. Amylase
  6. Bilirubin, TG, Cholesterol
  7. LDH
  8. PT, PTT, INR
  9. Uric acid
  10. BUN, Creatinine
  11. Ca, Mg
  12. Phosphorus
  13. Protein


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