Alcoholism

Introduction

Alcohol (beverage ethanol) distributes throughout the body, affecting almost all systems and altering nearly every neurochemical process in the brain. This drug is likely to exacerbate most medical conditions, affect almost any medication metabolized in the liver, and temporarily mimic many medical (e.g., diabetes) and psychiatric (e.g., depression) conditions. Because 80% of people in Western countries have consumed alcohol, and two-thirds have been drunk in the prior year, the lifetime risk for serious, repetitive alcohol problems is almost 20% for men and 10% for women, regardless of a person's education or income.

Pharmacology and Nutritional Impact of Ethanol

Blood levels of ethanol are expressed as milligrams or grams of ethanol per deciliter (e.g., 100 mg/dL = 0.10 g/dL), with values of 0.02 g/dL resulting from the ingestion of one typical drink. In round figures, 340 mL (12 oz) of beer, 115 mL (4 oz) of nonfortified wine, and 43 mL (1.5 oz) (a shot) of 80-proof beverage such as whisky, gin, or vodka each contain 10–15 g of ethanol and represent a standard drink;0.5 L (1 pint) of 80-proof beverage contains 160 g (about 16 standard drinks), and 750 mL of wine contains 60 g of ethanol.

Definitions and Epidemiology

Alcohol dependence is defined in DSM-IV as repeated alcohol-related difficulties in at least three of seven life areas that cluster together at about the same time (e.g., over the same 12-month period). Two of these seven items, tolerance and withdrawal, may have special importance as they are associated with a more severe clinical course. Dependence predicts a course of recurrent problems with the use of alcohol and the consequent shortening of the life span by a decade.

Myths

Most alcoholics are skid-row bumsMixing drinks makes you drunk fasterBlack coffee or cold showers can sober you

upBeer drinkers are less likely to become

alcoholicsSex is better after a few drinks

Stages of Alcoholism

Introductory StageEarly, Forewarning StageMiddle Crucial StageFinal Chronic Stage

Conditions of Alcoholism

Consumption of large quantities over an extended period.

Psychological dependencePhysical addictionAlcohol-related problems

Effects of alcohol

Short-term (individual)Long-Term (individual)Social EffectsCrime & Alcohol

Social Profile

Gender & AgeRace & EthnicityReligious AffiliationSocio-economic statusRegion

Theories of Alcoholism

Genetic Theories:“A” geneBlushing responseThe Alcoholic PersonalitySociological Theories – degree of fit

Controlling alcohol use & abuse

Legal measuresProhibitionAge limitsTherapeutic approachesAARational recovery

Acute Intoxication

Aggressive behavior should be handled by offering reassurance but also by considering the possibility of a show of force with an intervention team. If the aggressive behavior continues, relatively low doses of a short-acting benzodiazepine such as lorazepam (e.g., 1–2 mg PO or IV) may be used and can be repeated as needed, but care must be taken not to destabilize vital signs or worsen confusion. An alternative approach is to use an antipsychotic medication (e.g., 0.5–5 mg of haloperidol PO or IM every 4–8 h as needed, or olanzapine 2.5–10 mg IM repeated at 2 and 6 h, if needed).

Intervention

There are two main elements to intervention in a person with alcoholism: motivational interviewing and brief interventions. During motivational interviewing, the clinician helps the patient to think through the assets (e.g., comfort in social situations) and liabilities (e.g., health and interpersonal related problems) of the current pattern of drinking.

Once the patient begins to consider change, the emphasis shifts to brief interventions designed to help the patient understand more about potential action. Discussions focus on consequences of high alcohol consumption, suggested approaches to stopping drinking, and help in recognizing and avoiding situations likely to lead to heavy drinking.

Alcohol Withdrawal

Features include tremor of the hands (shakes); agitation and anxiety; autonomic nervous system overactivity including an increase in pulse, respiratory rate, and body temperature; and insomnia. These symptoms usually begin within 5–10 h of decreasing ethanol intake, peak on day 2 or 3, and improve by day 4 or 5, although mild levels of these problems may persist for 4–6 months as a protracted abstinence syndrome.

Alcohol Withdrawal

It is also important to offer adequate nutrition and oral multiple B vitamins, including 50–100 mg of thiamine daily for a week or more. Because most alcoholics who enter withdrawal are either normally hydrated or mildly overhydrated, IV fluids should be avoided unless there is a relevant medical problem or significant recent bleeding, vomiting, or diarrhea.

The average patient requires doses of 25–50 mg of chlordiazepoxide or 10 mg of diazepam given PO every 4–6 h on the first day, with doses then decreased to zero over the next 5 days.

Medications for Rehabilitation

Several medications have modest benefits when used for the first 6 months of recovery. The opioid-antagonist, naltrexone, 50–150 mg/d orally, appears to shorten subsequent relapses, whether used in the oral form or as a once-per-month 380-mg injection, especially in individuals with the G allele of the AII8G polymorphism of the opioid receptor.