> Table of Contents > Alcohol Abuse and Dependence
Alcohol Abuse and Dependence
Gennine M. Zinner, RNCS, ANP
image BASICS
DESCRIPTION
  • Any pattern of alcohol use causing significant physical, mental, or social dysfunction; key features are tolerance, withdrawal, and persistent use despite problems.
  • Alcohol abuse: maladaptive pattern of alcohol use manifested by ≥ 1 of:
    • Failure to fulfill obligations at work, school, or home
    • Recurrent use in hazardous situations
    • Recurrent alcohol-related legal problems
    • Continued use despite related social or interpersonal problems
  • Alcohol dependence: maladaptive pattern of use manifested by ≥ 3 of the following:
    • Tolerance
    • Withdrawal
    • Using more than intended
    • Persistent desire or attempts to cut down/stop
    • Significant amount of time obtaining, using, or recovering from alcohol
    • Social, occupational, or recreational activities sacrificed for alcohol use
    • Continued use despite physical or psychological problems
  • 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
  • System(s) affected: nervous, gastrointestinal (GI)
  • Synonym(s): alcoholism, alcohol abuse, alcohol dependence
Geriatric Considerations
  • 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 γ-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.
image DIAGNOSIS
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
    • γ-glutamyl transferase (GGT)
    • P.33

    • Carbohydrate-deficient transferrin
    • Elevated mean corpuscular volume (MCV)
    • ↑ Prothrombin time
    • Uric acid
    • ↑ 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
image 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
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
image 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.
REFERENCES
1. 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.
2. 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.
3. 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.
4. 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.
5. Miller PM, Book SW, Stewart SH. Medical treatment of alcohol dependence: a systematic review. Int J Psychiatry Med. 2011;42(3):227-266.
6. Rösner 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
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