Lifetime risk for alcohol use disorder is 10–15% for men and 5–8% for women. Typically, the first major life problem from excessive alcohol use appears in early adulthood, followed by periods of exacerbation and remission. The course is not hopeless; following treatment, between half and two-thirds of pts maintain abstinence for years and often permanently. If the alcoholic continues to drink, life span is shortened by an average of 10 years due to increased risk of death from heart disease, cancer, accidents, or suicide.
Screening for alcoholism is important given its high prevalence. Standardized questionnaires can be helpful in busy clinical practices including the 10-item Alcohol Use Disorders Identification Test (AUDIT) (Table 199-2).
TABLE 199-2THE ALCOHOL USE DISORDERS IDENTIFICATION TEST (AUDIT)a ||Download (.pdf) TABLE 199-2THE ALCOHOL USE DISORDERS IDENTIFICATION TEST (AUDIT)a
|Item ||5-Point Scale (Least to Most) |
|1. How often do you have a drink containing alcohol? ||Never (0) to 4+ per week (4) |
|2. How many drinks containing alcohol do you have on a typical day? ||1 or 2 (0) to 10+ (4) |
|3. How often do you have six or more drinks on one occasion? ||Never (0) to daily or almost daily (4) |
|4. How often during the last year have you found that you were not able to stop drinking once you had started? ||Never (0) to daily or almost daily (4) |
|5. How often during the last year have you failed to do what was normally expected from you because of drinking? ||Never (0) to daily or almost daily (4) |
|6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? ||Never (0) to daily or almost daily (4) |
|7. How often during the last year have you had a feeling of guilt or remorse after drinking? ||Never (0) to daily or almost daily (4) |
|8. How often during the last year have you been unable to remember what happened the night before because you had been drinking? ||Never (0) to daily or almost daily (4) |
|9. Have you or someone else been injured as a result of your drinking? ||No (0) to yes, during the last year (4) |
|10. Has a relative, friend, doctor, or other health worker been concerned about your drinking or suggested that you should cut down? ||No (0) to yes, during the last year (4) |
Routine medical care requires attention to potential alcohol-related illness and to alcoholism itself:
Neurologic: blackouts, seizures, delirium tremens (DTs), cerebellar degeneration, neuropathy, myopathy
GI: esophagitis, gastritis, pancreatitis, hepatitis, cirrhosis, GI hemorrhage
Cardiovascular: hypertension, cardiomyopathy
Hematologic: macrocytosis, folate deficiency, thrombocytopenia, leukopenia
Endocrine: gynecomastia, testicular atrophy, amenorrhea, infertility
Skeletal: fractures, osteonecrosis
Cancer: breast cancer, oral and esophageal cancers, rectal cancers
Alcohol is a CNS depressant that acts on receptors for γ-aminobutyric acid (GABA), the major inhibitory neurotransmitter in the nervous system. Behavioral, cognitive, and psychomotor changes can occur at blood alcohol levels as low as 0.02–0.03 g/dL, a level achieved after the ingestion of one or two typical drinks. “Legal intoxication” in most states requires a blood alcohol concentration of 0.08 g/dL; levels twice this can lead to deep but disturbed sleep. Incoordination, tremor, ataxia, confusion, stupor, coma, and even death occur at progressively higher blood alcohol levels.
Chronic alcohol use produces CNS dependence, and the earliest sign of alcohol withdrawal is tremulousness (“shakes” or “jitters”), occurring 5–10 h after decreasing ethanol intake. This may be followed by generalized seizures in the first 24–48 h; these do not require initiation of antiseizure medications. With severe withdrawal, autonomic hyperactivity ensues (sweating, hypertension, tachycardia, tachypnea, fever), accompanied by insomnia, nightmares, anxiety, and GI symptoms.
A very severe withdrawal syndrome characterized by profound autonomic hyperactivity, extreme confusion, agitation, vivid delusions, and hallucinations (often visual and tactile) that begins 3–5 days after the last drink. Mortality is 5–15%.
An alcohol-related syndrome characterized by ataxia, ophthalmoplegia, and confusion, often with associated nystagmus, peripheral neuropathy, cerebellar signs, and hypotension; there is impaired short-term memory, inattention, and emotional lability. Wernicke-Korsakoff’s syndrome follows, characterized by anterograde and retrograde amnesia and confabulation. Wernicke-Korsakoff’s syndrome is caused by chronic thiamine deficiency, resulting in damage to thalamic nuclei, mammillary bodies, and brainstem and cerebellar structures.