Alcohol-Related Disorders
DEFINITION
- Alcohol use disorders are medical conditions that are diagnosed when a patient’s drinking causes significant concern or harm, and decrease in functioning. They were formerly classified as either alcohol dependence (alcoholism) or alcohol abuse.
EPIDEMIOLOGY
- Lifetime prevalence: men 10%, women 5%
- Groups at increased risk: Individuals with a family history of alcoholism, trauma victims, and persons with personality disorders (borderline and antisocial)
- Earlier exposure to alcohol increases risk
- Quick development of high tolerance is predictive of developing dependence.
- Genes account for approximately 60% of variance in developing alcohol dependence.
- Estimated cost of alcohol abuse in the U.S. was $249 billion in 2010 according to the CDC.
DIAGNOSIS
Clinical Presentation
Clinical Presentation
- No typical pattern describes the progression from heavy drinking to problematic drinking, but certain features appear to be dominant:
- Binge drinking or drinking to the point of intoxication
- Increased tolerance to alcohol
- Cravings to drink
- Consequences from drinking: taking sick days from work, breakdown of interpersonal relationships, driving under the influence, legal problems, traumatic events
- Blackouts (amnestic events during drinking)
- Worsening of hangovers
- Feelings of guilt, remorse, regret, or disgust over drinking, yet difficulty reducing intake
- Concealment of drinking
- Withdrawal with cessation of drinking
- Physical features:
- Arcus senilis
- Tremor
- Hypertension
- Rhinophyma
- Telangiectasias
- Impaired cognitive function
- Signs of liver failure
- Signs of physical trauma
- Medical complications:
- Respiratory suppression: can occur after acute consumption of large amounts of alcohol and can be fatal
- Wernicke’s encephalopathy: triad of ophthalmoplegia, ataxia, and confusion due to thiamine deficiency, reversible
- Korsakoff syndrome: also due to thiamine deficiency and associated with short-term memory impairment, often irreversible
- Alcohol withdrawal syndrome
- Mild to moderate withdrawal (6-24 hrs after last drink): tremor, anxiety, insomnia, tachycardia, hypertension, diaphoresis, nausea, paresthesia, perceptual disturbances
- Alcohol-induced psychotic disorder or hallucinosis (12 hrs after last drink): visual hallucinations of animals; auditory hallucinations of unformed sounds or derogatory voices
- Seizures (48 hrs after last drink): generalized tonic-clonic motor seizures, can present in clusters
- Alcohol withdrawal delirium or delirium tremens (72-96 hrs after last drink): altered sensorium, severe agitation, hallucinations without insight, profound sympathetic hyperactivity
- Esophageal varices
- Gastritis
- Pancreatitis
- Alcoholic hepatitis
- Cirrhosis or fatty liver
- Cardiomyopathy
- Macrocytic anemia
- Peripheral neuropathy
- Fetal alcohol syndrome
- Impaired sexual functioning
- Increased risk of throat, mouth, breast cancer
- Increased risk of death from motor vehicle accidents, falls, accidental drowning, suicide
Tests and Procedures
Tests and Procedures
- Screening for at-risk alcohol consumption
- Single question screen: How many times in the past year have you had >5(men)/>4(women) drinks in a day? If answer >1 time(s), then positive screen
- 1 standard drink = 12 oz beer, 5 oz wine, or 1.5 oz 80-proof spirits
- Alcohol Use Disorders Identification Test (AUDIT)
- 10-item questionnaire, assesses alcohol consumption and consequences of use
- Positive score >8 for men, >4 for women
- Liver function tests: aspartate transferase (AST):alanine transferase (ALT) ratio = 2:1 is suggestive of excessive alcohol consumption
- Elevated gamma-glutamyl transpeptidase (GGT): 70-80% sensitive and specific
- Elevated percent carbohydrate deficient transferrin (CDT): 70-80% specific
- Triglycerides, uric acid and bilirubin are typically elevated
- Raised mean corpuscular volume (MCV)
- Elevated amylase and lipase with alcoholic pancreatitis
- Early Detection of Alcohol Consumption (EDAC) score: Score obtained from a panel of 25 hematology and chemistry tests that may predict heavy drinking
- Single question screen: How many times in the past year have you had >5(men)/>4(women) drinks in a day? If answer >1 time(s), then positive screen
- Testing for alcohol ingestion
- Blood alcohol concentration (mg/dL)
- Breathalyzers (g/210 L)
- Serum phosphatidylethanol (PEth)- can detect heavy alcohol consumption up to a month after cessation of drinking
- Urine testing: qualitative measures which can be used to monitor ongoing abstinence
- Urine alcohol: detected during acute intoxication
- Urine ethyl glucuronide (Etg): very sensitive and can detect alcohol in the urine 5-7 days after consumption. False positives can occur with use of alcohol-based mouthwashes or hand sanitizer.
Differential Diagnosis
Differential Diagnosis
- Brain trauma
- Electrolyte disturbances
- Hypoglycemia
- Ketoacidosis (diabetic)
- Meningitis
- Neurological conditions such as multiple sclerosis
- Stroke
- Pneumonia or sepsis
TREATMENT
General
General
- Treatment of acute intoxication is usually not needed as effects subside with time, but flumazenil can be used to reverse respiratory suppression.
- Treatment of the chronic sequelae of alcohol use disorders is directed at treating the complications listed above.
Pharmacotherapy
Pharmacotherapy
- Alcohol withdrawal treatment
- Mild-moderate withdrawal
- Benzodiazepines are the treatment of choice, effective at preventing alcohol withdrawal seizures and delirium.
- Symptom-triggered dosing is associated with less use of medication and shorter duration of treatment.
- Use an alcohol withdrawal severity scale such as the Clinical Institute Withdrawal Assessment-Alcohol, Revised (CIWA-Ar) to guide treatment
- Administer benzodiazepine every hour until CIWA-Ar < 8. Then continue to monitor with CIWA-Ar q4-8 hrs until score < 8 x 24 hrs.
- Benzodiazepine dosages:
- Chlordiazepoxide 50-100 mg PO
- Diazepam 10-20 mg PO/IV
- Oxazepam 30-60 mg PO
- Lorazepam 2-4 mg PO/IV/IM
- Use lorazepam or oxazepam in patients with impaired liver functioning.
- Select anticonvulsants have demonstrated similar efficacy to benzodiazepines at managing withdrawal symptoms.
- Anticonvulsants tend to cause less sedation than benzodiazepines.
- Studies were generally underpowered to compare rates of seizures of DTs.
- Carbamazepine 600-800 mg or gabapentin 1200-1800 mg total daily compared favorably to Lorazepam 6-8 mg total daily.
- Mild-moderate withdrawal
- Alcohol withdrawal seizures
- Give initial IV dose of rapid-acting benzodiazepine (diazepam, lorazepam).
- Follow with PO loading doses of benzodiazepine to prevent seizure recurrence.
- Rule out trauma, infectious causes.
- Phenytoin is not useful in managing seizures due to alcohol withdrawal.
- Delirium tremens
- Give diazepam 5mg IV q5 min x 2 doses, increase as needed to 10 mg q5 min x 2 doses, then 20 mg x q5 min x 2 doses, until light sedation achieved.
- Close respiratory monitoring is needed.
- Correct fluid and electrolyte imbalances.
- Evaluate and treat for other causes of delirium.
- Refractory cases not responsive to typical dosages of benzodiazepines may need endotracheal intubation and ICU admission. Adjunctive treatment with phenobarbital, propofol or dexmedetomidine have reportedly been helpful.
- High mortality rate if untreated. Death is typically caused by pneumonia, cardiovascular complications, and trauma.
- Adjunctive medications used for withdrawal management
- Haloperidol 2-5 mg PO/IV/IM for agitation/hallucinations not responding to benzodiazepines. Use cautiously, as neuroleptics can reduce seizure threshold.
- Carbamazepine 200 mg PO qid tapered over 5-10 days. May help reduce severity of withdrawal symptoms and prevent seizures.
- Valproic acid and gabapentin are anticonvulsants that have shown some positive results in mitigating withdrawal symptoms.
- Wernicke-Korsakoff syndrome:
- Prophylaxis: Thiamine 500 mg IV/IM daily x 3-5 days
- Treatment: Thiamine 500 mg IV tid x 3 days followed by 250 mg IV daily x 5 days
- Give IV thiamine as slow infusion over 30 min to minimize risk of anaphylaxis.
- Oral thiamine is poorly absorbed and not as helpful as IV treatment.
- Administer thiamine before giving glucose, which can precipitate the disorder.
- Replace fluids and electrolytes, including magnesium as needed.
- FDA-approved medications for treatment of alcohol dependence
- Disulfram
- Dosage: 250 mg-500 mg PO daily
- Inhibits action of aldehyde dehydrogenase, which results in high concentrations of aldehyde after alcohol ingestion, causing an aversive reaction
- More effective when taken under supervision
- Aversive symptoms include headache, nausea, vomiting, skin flushing, shortness of breath, diaphoresis, dizziness, confusion, palpitations, and hypotension.
- More severe reactions can occur, including cardiovascular collapse and seizures.
- May cause hepatic impairment/hepatitis, so monitoring of LFTs is recommended.
- Naltrexone
- Dosage: 50-100 mg PO daily, extended-release injectable dosage 380 mg IM q4 weeks
- μ-opioid receptor antagonist; blocks rewarding effect of alcohol on endogenous opioid system
- Effect size is small, but naltrexone has consistently shown reduction in heavy drinking in randomized controlled trials, especially in combination with psychotherapy.
- Side effects: nausea, headache, dizziness
- May precipitate opioid withdrawal: Patients should have an opioid-free period of 7-10 days before starting.
- Black box warning for hepatotoxicity. Consider LFT monitoring.
- Acamprosate
- Dosage: 666 mg PO tid
- Mechanism of action is unclear, but it probably helps restore GABA/glutamate balance after prolonged drinking.
- Side effects: GI complaints (diarrhea)
- Excreted unchanged in the urine, so useful in patients with liver impairment
- Disulfram
- Medications used off-label for treatment of alcohol dependence:
- Ondansetron
- Dosage: 4-8 μg/kg PO bid
- Selective 5-HT3 receptor antagonist
- May be more effective in patients with early-onset alcoholism and with the LL (long) variant of the presynaptic 5-HT transporter gene
- Side effects: headache, GI disturbances, tachycardia, prurititis, insomnia
- Topiramate
- Dosage: start at 25 mg PO daily, and titrate to 150 mg bid over 12 days
- Anticonvulsant which enhances GABA function
- Side effects: paresthesias, weight loss, dysgeusia, concentration or memory impairment, fatigue
- Excreted unchanged in the urine, so useful in patients with liver impairment
- Baclofen
- Dosage: 5-10 mg PO tid
- Presynaptic GABAB receptor agonist
- Randomized controlled trials show mixed results in reducing alcohol intake
- Side effects: headache, nausea, insomnia, hypotension, urinary frequency
- Excreted through kidneys, so useful in patients with liver impairment
- Other medications used: gabapentin, varenicline, prazosin, levetiracetam
- Ondansetron
Psychotherapy
Psychotherapy
- Treatment generally starts with the individual’s recognition that the disorder is present.
- Referral to a 12-step program (Alcoholics Anonymous) is probably the best known psychological intervention.
- Cognitive-behavioral therapy: focuses on situations and triggers for use
- Motivational enhancement therapy
- Brief interventions: counseling and therapy provided by primary care providers targeted at reducing risky or hazardous drinking
- Relapse prevention therapy: helps patients identify and cope with high-risk situations and manage cravings
- Project Match conducted a randomized-controlled trial to compare 3 treatments: motivational enhancement therapy, cognitive behavioral therapy, and 12-step facilitation. All treatment modalities were equally efficacious, and >50% of patients remained abstinent or reduced their drinking at 1 and 3 years post-treatment.
WHEN TO REFER
It is appropriate to refer someone to treatment for an alcohol use disorder whenever it is felt that alcohol consumption is interfering with normal functioning.
FOLLOW UP
- Follow-up should occur frequently after the initial cessation of alcohol consumption and be tapered as felt to be appropriate by an addictionologist or other trained health care professional.
- Maintenance of sobriety requires lifelong vigilance, and individualized care is necessary.
COMMENTS
- Despite advances in the treatment of alcohol use disorders, individuals often relapse several times before obtaining abstinence.
- There may be some advantages to a harm reduction approach that aims to reduce alcohol consumption to non-pathologic levels while maintaining the ultimate goal of abstinence.
References
- American Psychiatric Association. (2013) Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
- Anton RF, O'Malley SS, Ciraulo DA, et al. Combined pharmacotherapies and behavioral interventions for alcohol dependence: the COMBINE study: a randomized controlled trial. JAMA. 2006;295(17):2003-17. [PMID:16670409]
- Hammond CJ, Niciu MJ, Drew S, et al. Anticonvulsants for the treatment of alcohol withdrawal syndrome and alcohol use disorders. CNS Drugs. 2015;29(4):293-311. [PMID:25895020]
- Harasymiw JW, Vinson DC, Bean P. The early detection of alcohol consumption (EDAC) score in the identification of Heavy and at-risk drinkers from routine blood tests. J Addict Dis. 2000;19(3):43-59. [PMID:11076119]
- Jarosz J, Miernik K, Wąchal M, et al. Naltrexone (50 mg) plus psychotherapy in alcohol-dependent patients: a meta-analysis of randomized controlled trials. Am J Drug Alcohol Abuse. 2013;39(3):144-60. [PMID:23721530]
- Johnson BA. Medication treatment of different types of alcoholism. Am J Psychiatry. 2010;167(6):630-9. [PMID:20516163]
- Maisel NC, Blodgett JC, Wilbourne PL, et al. Meta-analysis of naltrexone and acamprosate for treating alcohol use disorders: when are these medications most helpful? Addiction. 2013;108(2):275-93. [PMID:23075288]
- Matching Alcoholism Treatments to Client Heterogeneity: Project MATCH posttreatment drinking outcomes. J Stud Alcohol. 1997;58(1):7-29. [PMID:8979210]
- Matching alcoholism treatments to client heterogeneity: Project MATCH three-year drinking outcomes. Alcohol Clin Exp Res. 1998;22(6):1300-11. [PMID:9756046]
- Mayo-Smith MF. Pharmacological management of alcohol withdrawal. A meta-analysis and evidence-based practice guideline. American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal. JAMA. 1997;278(2):144-51. [PMID:9214531]
- Mayo-Smith MF, Beecher LH, Fischer TL, et al. Management of alcohol withdrawal delirium. An evidence-based practice guideline. Arch Intern Med. 2004;164(13):1405-12. [PMID:15249349]
- McCowan C, Marik P. Refractory delirium tremens treated with propofol: a case series. Crit Care Med. 2000;28(6):1781-4. [PMID:10890619]
- Müller CA, Geisel O, Banas R, et al. Current pharmacological treatment approaches for alcohol dependence. Expert Opin Pharmacother. 2014;15(4):471-81. [PMID:24456374]
- National Institute on Alcohol Abuse and Alcoholism. www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/alcohol-use-disorders
- National Institute on Alcohol Abuse and Alcoholism: Helping Patients Who Drink Too Much: A Clinician’s Guide: Updated 2005 Edition (NIH Publication No. 07—3769) . Bethesda, MD, US Department of Health and Human Services, 2005
- Ruiz, P., Strain, E.C., Langrod, JG. The Substance Abuse Handbook. Philadelphia, PA: Lippincott Williams and Wilkins, a Wolters Kluwer business; 2007.
- Rösner S, Hackl-Herrwerth A, Leucht S, et al. Opioid antagonists for alcohol dependence. Cochrane Database Syst Rev. 2010. [PMID:21154349]
- Saitz R, Mayo-Smith MF, Roberts MS, et al. Individualized treatment for alcohol withdrawal. A randomized double-blind controlled trial. JAMA. 1994;272(7):519-23. [PMID:8046805]
- Thomson AD, Cook CC, Touquet R, et al. The Royal College of Physicians report on alcohol: guidelines for managing Wernicke's encephalopathy in the accident and Emergency Department. Alcohol Alcohol. 2002;37(6):513-21. [PMID:12414541]
- Thomson AD, Marshall EJ. The treatment of patients at risk of developing Wernicke's encephalopathy in the community. Alcohol Alcohol. 2006;41(2):159-67. [PMID:16384870]
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Last updated: May 2, 2017
Citation
Hobelmann, J. G, and Jeffrey Hsu. "Alcohol-Related Disorders." Johns Hopkins Psychiatry Guide, 2017. Johns Hopkins Guides, www.hopkinsguides.com/hopkins/view/Johns_Hopkins_Psychiatry_Guide/787096/all/Alcohol_Related_Disorders.
Hobelmann JG, Hsu J. Alcohol-Related Disorders. Johns Hopkins Psychiatry Guide. 2017. https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_Psychiatry_Guide/787096/all/Alcohol_Related_Disorders. Accessed March 26, 2023.
Hobelmann, J. G., & Hsu, J. (2017). Alcohol-Related Disorders. In Johns Hopkins Psychiatry Guide https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_Psychiatry_Guide/787096/all/Alcohol_Related_Disorders
Hobelmann JG, Hsu J. Alcohol-Related Disorders [Internet]. In: Johns Hopkins Psychiatry Guide. ; 2017. [cited 2023 March 26]. Available from: https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_Psychiatry_Guide/787096/all/Alcohol_Related_Disorders.
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