Alcohol Use Disorder (Alcoholism)

Essentials of Diagnosis

• Major criteria

  • Physiologic dependence as evidenced by withdrawal when intake is interrupted

  • Tolerance to the effects of alcohol

  • Evidence of alcohol-associated illnesses, such as alcoholic liver disease, cerebellar degeneration

  • Continued drinking despite strong medical and social contraindications and life disruption

  • Impairment in social and occupational functioning

  • Depression

  • Blackouts

• Other signs

  • Alcohol odor on breath

  • Alcoholic facies

  • Flushed face

  • Scleral injection

  • Tremor

  • Ecchymoses

  • Peripheral neuropathy

  • Surreptitious drinking

  • Unexplained work absences

  • Frequent accidents, falls, or injuries

  • In smokers, cigarette burns on hands or chest

  • Laboratory tests: elevated values of mean corpuscular volume, serum liver biochemical tests, uric acid, and triglycerides

General Considerations

• The two-phase syndrome includes at-risk drinking and moderate to severe alcohol misuse

• At-risk drinking is the repetitive use of alcohol, often to alleviate anxiety or solve other emotional problems

  • For men, at-risk drinking is defined as > 4 drinks per day or 14 drinks per week

  • For women, at-risk drinking is defined as > 3 drinks per day or 7 drinks per week

• Moderate to severe alcoholism is similar to that which occurs following the repeated use of other sedative-hypnotics; characterized by

  • Recurrent use of alcohol despite disruption in social roles (family and work)

  • Alcohol-related legal problems

  • Taking safety risks by oneself and with others

• Alcoholism is associated with a high prevalence of lifetime psychiatric disorders, especially depression

Demographics

• Most suicides and intrafamily homicides involve alcohol

• Major factor in rapes and other assaults

• Male-to-female ratios of 4:1 are converging

• Adoption and twin studies indicate some genetic influence

• Forty percent of Japanese have aldehyde dehydrogenase deficiency, which increases susceptibility to the effects of alcohol

Symptoms and Signs

Acute intoxication

• Drowsiness, errors of commission, disinhibition, dysarthria, ataxia, and nystagmus

• Ataxia, dysarthria, and vomiting indicate a blood level > 150 mg/dL

• Lethal blood levels: 350–900 mg/dL

• Severe intoxication: respiratory depression, stupor, seizures, shock syndrome, coma, and death

• Serious overdoses often include other sedatives combined with alcohol

Withdrawal

• Categorized as mild, moderate, or severe withdrawal, withdrawal seizures, and delirium tremens (DTs)

• Symptoms of mild withdrawal

  • Tremor, anxiety, tachycardia, nausea and vomiting, insomnia

  • Begin about 6 hours after the last drink and end by day 2

• Symptoms of moderate withdrawal signs and symptoms fall between those of mild and severe

• Symptoms of severe withdrawal

  • Disorientation, agitation, diaphoresis, whole body tremor, vomiting, hypertension, and hallucinations (visual>tactile>auditory)

  • Occurs 48–96 hours after the last drink

  • Usually preceded by prolonged heavy alcohol use

• Withdrawal seizures

  • Occur as early as 8 hours after last drink

  • Do not manifest more than 48 hours after alcohol cessation

  • More prevalent in persons who have a history of withdrawal syndromes

  • These seizures are generalized tonic-clonic seizures, are brief in duration, and resolve spontaneously

  • If withdrawal is untreated, these seizures can recur in about 60% of patients

• Delirium tremens

  • An acute organic psychosis

  • Usually occurs within 48–72 hours after the last drink but may occur up to 7–10 days later

  • Extreme mental confusion, agitation, tremor

  • Diaphoresis

  • Sensory hyperacuity

  • Visual hallucinations (often of snakes, bugs)

  • Autonomic hyperactivity (tachycardia and hypertension)

  • Cardiac abnormalities

  • Dehydration

  • Electrolyte disturbances (hypokalemia, hypomagnesemia)

  • Seizures

• Acute alcohol withdrawal syndrome often occurs unexpectedly in patients hospitalized for an unrelated reason and presents a diagnostic dilemma

• Possible persistence of sleep disturbances, anxiety, depression, excitability, fatigue, and emotional volatility for 3–12 months, becoming chronic in some cases

Alcoholic hallucinosis

• Paranoid psychosis without the tremulousness, confusion, and clouded sensorium seen in withdrawal syndromes

• Occurs during heavy drinking or during withdrawal

• Patient appears normal except for the auditory hallucinations, which are frequently persecutory and may cause the patient to behave aggressively and in a paranoid fashion

Chronic alcoholic brain syndromes

• Encephalopathies

  • Increasingly erratic behavior

  • Memory and recall problems

  • Emotional lability

• Wernicke encephalopathy

  • Confusion

  • Ataxia

  • Ophthalmoplegia (typically sixth cranial nerve)

• Korsakoff psychosis is a sequela

  • Anterograde and retrograde amnesia

  • Confabulation early in the course

• Excessive alcohol consumption in men has been associated with faster cognitive decline compared with light to moderate alcohol consumption

Differential Diagnosis

• Must differentiate between primary alcohol use disorder and secondary alcohol use disorder

  • Primary alcohol use disorder: no other major psychiatric diagnosis exists

  • Secondary alcohol use disorder: alcohol is used as self-medication for major underlying psychiatric problems such as schizophrenia or affective disorder

  • This differentiation is important, since the latter group requires treatment for the underlying specific psychiatric problem

• Alcohol withdrawal

  • Other sedative withdrawals

  • Other causes of delirium

• Acute alcoholic hallucinosis must be differentiated from other acute paranoid states, such as amphetamine psychosis or paranoid schizophrenia

Laboratory Tests

• An unexplained osmolar gap may be present

• Increased serum liver biochemical tests, uric acid, and triglycerides and decreased serum potassium and magnesium

• Most definitive biologic marker for chronic alcoholism is carbohydrate- deficient transferrin, which can detect heavy use (60 mg/day over 7–10 days) with high specificity

• Serious drinking problem likely if there is elevation of

  • Gamma-glutamyl transpeptidase (GGT) (levels > 30 units/L suggest heavy drinking)

  • Mean corpuscular volume (> 95 fL in men and > 100 fL in women)

Diagnostic Procedures

• Suspect the problem early

• Perform the Alcohol Use Disorder Identification Test (AUDIT) (Table 1–6)

• Before treating for withdrawal or hallucinosis, meticulous examination for other medical problems is necessary

Medications

At-risk drinking

• Disulfiram (250–500 mg/day orally)

  • Inhibits aldehyde dehydrogenase, causing toxic reactions when alcohol is consumed

  • Compliance depends on motivation

• Naltrexone (50 mg/day orally)

  • Lowers 3- to 6-month relapse rates

  • Maintains abstinence

• Acamprosate (333–666 mg three times daily orally)

  • Reduces craving

  • Maintains abstinence

  • Can be continued during relapse

Hallucinosis and withdrawal

• Haloperidol, 5 mg orally twice a day for the first day or so

  • Usually ameliorates symptoms quickly

  • Can be decreased and discontinued over several days as patient improves

• A short course of oral tapering long-acting benzodiazepines, eg, diazepam, 20 mg/day orally initially, decreasing by 5 mg daily, may be a useful adjunct

• For all hospitalized patients, general management includes

  • Ensuring adequate hydration

  • Correcting electrolyte imbalances (particularly magnesium, calcium and potassium)

  • Administering thiamine, folic acid, and multivitamin

    • Thiamine: 100 mg intravenously daily for 3 days and then orally daily; should be given prior to any glucose-containing solutions to decrease the risk of precipitating Wernicke encephalopathy or Korsakoff syndrome)

    • Folic acid: 1 mg orally daily

    • Multivitamin: 1 dose orally daily

• Treatment of minimal withdrawal symptoms (Clinical Institute Withdrawal Assessment for Alcohol, Revised [CIW A-Ar] score < 8)

  • The recommended benzodiazepine options include chlordiazepoxide or lorazepam orally, tapered over 3 days

  • The protocol calls for nursing assessment of sedation and withdrawal symptoms (CIWA-Ar) every 6 hours

  • If prophylactic medication is indicated, a sample tapering regimen may include

    • Lorazepam 1 mg orally every 6 hours for 1 day, then 1 mg orally every 8 hours for 1 day, then 1 mg orally every 12 hours for 1 day then discontinue; may be used in patients with liver disease

    • Chlordiazepoxide 50 mg orally every 6 hours for 1 day, 25 mg orally every 6 hours for 2 days, then discontinue; avoid in patients with liver disease or the elderly

  • Sedation is assessed 30–60 minutes after each medication dose

  • The benzodiazepine dose is held for oversedation or if the respiratory rate is < 10 breaths per minute

• Treatment of mild withdrawal symptoms (CIWA-Ar score 8–15):

  • Either chlordiazepoxide orally or lorazepam orally or intravenously can be used

    • Initially, chlordiazepoxide 50 mg orally or lorazepam 1 or 2 mg orally or intravenously is given hourly for 2 hours

    • Dosing is adjusted as necessary to control symptoms without excessive sedation

    • After the first 2 hours, chlordiazepoxide (25–50mg orally) or lorazepam (0.5–1 mg orally or intravenously) may be given every 4 hours and as needed

  • Patients must be assessed for level of sedation and withdrawal symptoms (CIWA-Ar) every 4 hours

  • Additional doses of benzodiazepines should be given if the CIWA-Ar score remains 8–15

• Treatment of moderate withdrawal (CIWA-Ar 16–20):

  • Chlordiazepoxide 100 mg orally or lorazepam 3 or 4 mg orally or intravenously is given every hour for the first 2 hours

  • After initial dosing, continued treatment could include

    • Chlordiazepoxide 50 mg orally or lorazepam 1–2 mg orally or intravenously every 2 hours as needed for CIWA-Ar 15–20

    • Chlordiazepoxide 25 mg orally or lorazepam 0.5–1mg orally or intravenously every 2 hours for CIWA-Ar 8–15

    • The maximum dose of chlordiazepoxide is 600 mg in 24 hours

  • Dosing is adjusted to control symptoms without excessive sedation; degree of sedation should be monitored 30–60 minutes after each oral dose of medication and for 15 minutes after each parenteral dose

  • CIWA-Ar monitoring should occur every 2 hours

• Treatment of severe withdrawal (CIWA-Ar score > 20):

  • Lorazepam

    • Initial dosage: 1–2 mg intravenously every 15 minutes until patient is calm and sedated but awake

    • Initial CIWA monitoring should occur every 30 minutes

    • Taper dosage for CIWA-Ar 16–20: lorazepam 2 mg orally or intravenously every hour as needed for CIWA-Ar 16–20

    • For CIWA-Ar 8–15: lorazepam 1–2 mg orally or intravenously every 1 hour as needed

  • Consider adding dexmedetomidine to lorazepam if the patient requires > 8 mg per hour of lorazepam as an initial dose or continues to demonstrate observable agitation, tremors, tachycardia or hypertension despite high doses of lorazepam

    • Recommended dosing of dexmedetomidine is 0.2–0.7 mcg/kg/h with lorazepam 1–2 mg intravenously every 8 hours plus lorazepam 1–2 mg intravenously every hour as needed for agitation

    • Patients who are refractory to escalating benzodiazepine usage, despite the addition of dexmedetomidine, often require intubation for airway protection, at which time propofol infusion may be initiated

• Phenytoin is not useful for alcohol withdrawal seizures unless there is a preexisting seizure disorder

• Chronic alcoholic brain syndromes: Early recognition and treatment with intravenous thiamine and B complex vitamins can minimize damage

Therapeutic Procedures

• Maintain a nonjudgmental attitude

• Denial is best faced at the first meeting, preferably with family members

• Aversion behavioral therapy has been successful in some patients

• Motivational interviewing, a model of counseling that addresses both the patient's ambivalence and motivation for change, may contribute to reduced consumption over time

Follow-Up

• Monitoring of vital signs and fluid and electrolyte levels is essential for the severely ill patient with withdrawal

• Patients with alcoholic chronic brain syndrome require careful attention to their social and environmental care

Complications

• Nervous system complications

  • Chronic brain syndromes

  • Cerebellar degeneration

  • Cardiomyopathy

  • Peripheral neuropathies

• Direct liver effects

  • Cirrhosis

  • Esophageal varices

  • Eventual liver failure

• Indirect effects

  • Protein abnormalities

  • Coagulation defects

  • Hormone deficiencies

  • Increased incidence of liver neoplasms

• Fetal alcohol syndrome

• Complications of delirium tremens

  • Dehydration

  • Electrolyte disturbances (hypokalemia, hypomagnesemia)

  • Arrhythmias and seizures

  • If not properly treated, cardiovascular collapse and death

Prognosis

• The mortality rate from delirium tremens has steadily decreased with early diagnosis and improved treatment

When to Refer

• Alcoholics Anonymous (AA)

• Al-Anon for the spouse

When to Admit

• Hospitalization is usually not necessary but may be warranted if there are concomitant medical indications