Alcoholism
DEFINITION
Although it is impossible to define alcoholism precisely, among the commonly used screening instruments for this disorder are the CAGE questionnaire, short Michigan Alcoholism Screening Test (SMAST), National Council on Alcoholism criteria, and DSM-III-A criteria.Although not generally included under the topic alcoholism, hazardous or at-risk drinking should also be considered. For men, at-risk drinking is defined as greater than 14 drinks/week or more than 4 drinks/occasion. For women, at-risk drinking is defined as about half that given for men.
SYNONYMS
Alcohol abuse
Substance abuse
Substance abuse
EPIDEMIOLOGY & DEMOGRAPHICS
INCIDENCE (IN U.S.):
• See “Prevalence.”
• 20% achieve abstinence without help, 70% achieve sobriety for 1 yr.
PREVALENCE (IN U.S.): 7% of population 18 yr or older
PREDOMINANT SEX:
• Lifetime risk for males 8% to 10%
• Lifetime risk for females 3% to 5%
PEAK INCIDENCE: 20 to 40 yr
GENETICS: More common with a family history of alcoholism and in patients of Irish, Scandinavian, and Native American descent
• See “Prevalence.”
• 20% achieve abstinence without help, 70% achieve sobriety for 1 yr.
PREVALENCE (IN U.S.): 7% of population 18 yr or older
PREDOMINANT SEX:
• Lifetime risk for males 8% to 10%
• Lifetime risk for females 3% to 5%
PEAK INCIDENCE: 20 to 40 yr
GENETICS: More common with a family history of alcoholism and in patients of Irish, Scandinavian, and Native American descent
PHYSICAL FINDINGS & CLINICAL PRESENTATION
• Recurring minor trauma
• GI bleeding
• Pancreatitis
• Liver disease
• Odor of alcohol on breath
• Tremulousness
• Tachycardia
• Peripheral neuropathy
• Recent memory loss
• Table 1–7 describes some alcohol-related medical disorders.
• GI bleeding
• Pancreatitis
• Liver disease
• Odor of alcohol on breath
• Tremulousness
• Tachycardia
• Peripheral neuropathy
• Recent memory loss
• Table 1–7 describes some alcohol-related medical disorders.
ETIOLOGY
• Social and genetic factors important
• Risk factors:
1.Broken homes
2.Unemployment
3.Divorce
4.Recurrent depression
5.Addiction to another substance, including tobacco
• Risk factors:
1.Broken homes
2.Unemployment
3.Divorce
4.Recurrent depression
5.Addiction to another substance, including tobacco
DIAGNOSIS
WORKUP
• Screening tests (CAGE or SMAST)
• Blood studies
• Stool for occult blood
• Fig. 1–17 describes an algorithm for evaluation of alcohol abuse
• Blood studies
• Stool for occult blood
• Fig. 1–17 describes an algorithm for evaluation of alcohol abuse
LABORATORY TESTS
• ?-Glutamyltransferase (GGT)
• Aspartate aminotransferase (SGOT, AST)
• Mean corpuscular volume (MCV)
• Aspartate aminotransferase (SGOT, AST)
• Mean corpuscular volume (MCV)
IMAGING STUDIES
Indicated only if there is a history of trauma
TREATMENT
NONPHARMACOLOGIC THERAPY
• Abstinence.
• Depression, if present, should be treated at same time ETOH is withdrawn.
• Depression, if present, should be treated at same time ETOH is withdrawn.
ACUTE GENERAL Rx
• Observe for delirium tremens (DTs): if tachycardia or visual hallucinations occur, administer lorazepam or other benzodiazepines
• IM thiamine is mandatory in DTs and in acute extraocular disorders.
• IM thiamine is mandatory in DTs and in acute extraocular disorders.
Management of Alcohol Withdrawal*
- Observe and normalize vital signs
- Administer thiamine, 100 mg, then replace fluid and electrolytes
- Sedate with chlordiazepoxide, 25 mg PO qid
- Administer chlordiazepoxide, 25–50 mg IM prn for signs of withdrawal
- Use haloperidol (1–2 mg PO q4h prn) or thorazine cautiously for hallucinations or agitation
- Replace folic acid (1 mg/day PO) and thiamine (100 mg IM and then 100 mg/day PO)
- Give multivitamin daily
- Begin ß-blocker (atenolol, 50 mg) or clonidine (0.2 mg PO bid) to reduce adrenergic signs
CHRONIC Rx
• See “Referral.”
• Pharmacotherapies for alcoholism include the opiate antagonists (naltrexone 50 mg PO qd or nalmefene 10 to 40 mg qd), disulfiram, acamprosate, lithium, and SSRIs.
• Pharmacotherapies for alcoholism include the opiate antagonists (naltrexone 50 mg PO qd or nalmefene 10 to 40 mg qd), disulfiram, acamprosate, lithium, and SSRIs.
DISPOSITION
See “Referral”
REFERRAL
• To Alcoholics Anonymous or Adult Children of Alcoholics
• Family members to Al-Anon or Al-A-Teen
• Many cities have Salvation Army Adult Rehabilitation centers; all patients accepted, regardless of ability to pay
• Family members to Al-Anon or Al-A-Teen
• Many cities have Salvation Army Adult Rehabilitation centers; all patients accepted, regardless of ability to pay
PEARLS & CONSIDERATIONS
COMMENTS
The cure rate for alcoholism is very disappointing, regardless of the modality. Only those who want to be helped will be helped. An effective strategy for the primary care physician is a prominently displayed sign in the office that states, “If you think you consume too much alcoholic beverage, please discuss it with me.” Those who do open up the discussion can be given the facts in a nonjudgemental way and often can be helped. All too often, problem drinkers lie on the questionnaire until they face a life-threatening health issue—and even then denial often reigns supreme.
REFERENCES
Daeppen JB et al: Symptom-triggered vs fixed-schedule doses of benzodiazepine for alcohol withdrawal: a randomized treatment trial, Arch Intern Med 162:1117, 2002.
Enoch ME, Goldman D: Problem drinking and alcoholism: diagnosis and treatment, Am Fam Physician 65:441, 2002.
Fiellin DA et al: Outpatient management of patients with alcohol problems, Ann Intern Med 133:816, 2000.
Fleming MF et al: Brief physician advise for problem drinkers: long-term efficacy and benefit-cost analysis, Alcohol Clin Exp Res 26:36, 2002.
Garbutt JC et al: Pharmacological treatment of alcohol dependence: a review of the evidence, JAMA 281:1318, 1999.
Jaeger TM et al: Symptom triggered therapy for alcohol withdrawal syndrome in medical in patients, Mayo Clin Proc 76:695, 2001.
Krystal JH et al: Naltrexone in the treatment of alcohol dependence, N Engl J Med 345:1734, 2001.
Moyer A et al: Brief interventions for alcohol problems: a meta-analytic review of controlled investigations in treatment-seeking populations, Addiction 97:279, 2002.
Nicholas JM et al: The effect of controlled drinking in alcoholic cardiomyopathy, Ann Intern Med 136:192, 2002.
O’Connor PG, Schotrenfeld RS: Patients with alcohol problems, N Engl J Med 9:592, 1998.
Reid MC et al: Hazardous and harmful alcohol consumption in primary care, Arch Intern Med 159:1681, 1999.
Schneekloth TD et al: Point prevalence of alcoholism in hospitalized patients: continuing challenges of detection, assessment, and diagnosis, Mayo Clin Proc 76:460, 2001.
White IR et al: Alcohol consumption and mortality: modelling risks for men and women at different ages, BMJ 325:191, 2002.
Enoch ME, Goldman D: Problem drinking and alcoholism: diagnosis and treatment, Am Fam Physician 65:441, 2002.
Fiellin DA et al: Outpatient management of patients with alcohol problems, Ann Intern Med 133:816, 2000.
Fleming MF et al: Brief physician advise for problem drinkers: long-term efficacy and benefit-cost analysis, Alcohol Clin Exp Res 26:36, 2002.
Garbutt JC et al: Pharmacological treatment of alcohol dependence: a review of the evidence, JAMA 281:1318, 1999.
Jaeger TM et al: Symptom triggered therapy for alcohol withdrawal syndrome in medical in patients, Mayo Clin Proc 76:695, 2001.
Krystal JH et al: Naltrexone in the treatment of alcohol dependence, N Engl J Med 345:1734, 2001.
Moyer A et al: Brief interventions for alcohol problems: a meta-analytic review of controlled investigations in treatment-seeking populations, Addiction 97:279, 2002.
Nicholas JM et al: The effect of controlled drinking in alcoholic cardiomyopathy, Ann Intern Med 136:192, 2002.
O’Connor PG, Schotrenfeld RS: Patients with alcohol problems, N Engl J Med 9:592, 1998.
Reid MC et al: Hazardous and harmful alcohol consumption in primary care, Arch Intern Med 159:1681, 1999.
Schneekloth TD et al: Point prevalence of alcoholism in hospitalized patients: continuing challenges of detection, assessment, and diagnosis, Mayo Clin Proc 76:460, 2001.
White IR et al: Alcohol consumption and mortality: modelling risks for men and women at different ages, BMJ 325:191, 2002.
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