Alcohol dependence information for clients

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.

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

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)
  • Increased risk of traffic injuries, falls, drowning, burns and unintentional firearm injuries
• Violence:
  • Increased intimate partner violence, child maltreatment and neglect
• Risky sexual behaviors
  • Increased risk of unprotected sex, sex with multiple partners, sexual assault, unintended pregnancy or sexually transmitted diseases (Naimi et al 2003; Wechsler et al 1994)
• Increased risk of miscarriage and stillbirth among pregnant women, and a combination of physical and mental birth defects among children that last throughout life. (Kesmodel 2002)

Long-Term Health Risks

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

• 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.

• Kindeling is an important concept in both alcohol craving and alcohol withdrawal
• It refers to long-term changes that occur in neurons after repeated detoxifications.
• Recurrent detoxifications are postulated to increase obsessive thoughts or alcohol craving
• 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.

•  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.

• 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.

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. Losing tolerance
14. Black outs
15. Repeated intoxication
16. History of 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

1. They will take your blood pressure and pulse rate
2. They will examine your heart for rapid heart rate, abnormal heart rates (arrhythmias), or signs of heart failure
3. Assess for signs of gastrointestinal bleeding
4. Examine for liver disease and cirrhosis
5. Examine for neuropathy and pancreatitis

• 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.
• In using the CIWA-Ar, the clinical picture should be considered because medical and psychiatric conditions may mimic alcohol withdrawal symptoms.
• Certain medications (e.g., beta blockers) may blunt the manifestation of these symptoms.

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

Treatment of alcohol dependence is complex and requires a combination of medical, behavioural and psychosocial approaches.

Medications that are currently used for treatment of alcohol dependence can be classified as:

1. Abuse prevention:
   1. Antabuse
2. Seizure prevention and anxiety reduction:
   1. Benzodiazepines
   2. Gabapentin
   3. Phenobarbital
   4. Carbamazepin
3. Craving reduction and relapse prevention:
   1. Naltrexone
   2. Campral

Behavioral approaches:

• Cognitive behavioral therapy

Psychosocial approaches: 

• Attending AA groups
• Regular counseling
• Family support

The AWARE Questionnaire (Advance WArning of RElapse) is a questionnaire that is commonly used to predict the risk of relapse.

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