Alcohol Abuse

• Fred F. Ferri, M.D.

 Basic Information

Definition

Moderate drinking has been defined as two standard drinks (e.g., 12 oz of beer) per day and one drink per day for women and persons older than 65 yr. Although not generally included under the alcoholism topic, hazardous or at-risk drinking should also be considered. For men, at-risk drinking is defined as more than 14 drinks/wk or more than 4 drinks/occasion. For women, at-risk drinking is defined as approximately half that given for men.

The American Psychiatric Association defines diagnostic criteria for alcohol withdrawal as follows:

1. A.

   Cessation of (or reduction in) alcohol use that has been heavy and prolonged.

2. B.

   Two (or more) of the following, developing within several hours to a few days after criterion A:

   1. 1.

      Autonomic hyperactivity (e.g., sweating or pulse rate >100 beats/min)

   2. 2.

      Increased hand tremor

   3. 3.

      Insomnia

   4. 4.

      Nausea and vomiting

   5. 5.

      Transient visual, tactile, or auditory hallucinations or illusions

   6. 6.

      Psychomotor agitation

   7. 7.

      Anxiety

   8. 8.

      Grand mal seizures

3. C.

   The symptoms in criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

The symptoms are not attributable to a general medical condition and are not better accounted for by another mental disorder.

Synonyms

1. Alcohol abuse

2. Substance abuse

ICD-10CM CODES
F10	Mental and behavioral disorders due to use of alcohol
F10.1	Mental and behavioral disorders due to use of alcohol: harmful use
F10.2	Mental and behavioral disorders due to use of alcohol: dependence syndrome
F10.3	Mental and behavioral disorders due to use of alcohol: withdrawal state
F10.4	Mental and behavioral disorders due to use of alcohol: withdrawal state with delirium
F10.5	Mental and behavioral disorders due to use of alcohol: psychotic disorder
F10.6	Mental and behavioral disorders due to use of alcohol: amnesic syndrome

Epidemiology & Demographics

Incidence (In U.S.)

1. •

   The clinical history suggests alcohol problems in 15% to 20% of patients in primary care and hospitalized patients. In the U.S., alcohol abuse generates nearly $223 billion in annual economic costs. An estimated 14% of adults in the U.S. have alcohol dependence.

2. •

   20% achieve abstinence without help; 70% achieve sobriety for 1 yr.

Prevalence (In U.S.)

7% of population ≥18 yr

Predominant Sex

1. •

   Lifetime risk for males 8% to 10%

2. •

   Lifetime risk for females 3% to 5%

Peak Incidence

20 to 40 yr. The most common age range for initial treatment of alcohol dependence is 35 to 45 yr. However, the peak period for meeting alcohol dependence criteria is ≥10 years earlier.

Genetics

More common with a family history of alcoholism and in patients of Irish, Scandinavian, and Native American descent

Physical Findings & Clinical Presentation

1. •

   Recurring minor trauma

2. •

   Gastrointestinal bleeding from gastritis and/or varices

3. •

   Pancreatitis (acute and chronic)

4. •

   Liver disease

5. •

   Odor of alcohol on breath

6. •

   Tremulousness

7. •

   Tachycardia

8. •

   Peripheral neuropathy

9. •

   Recent memory loss

Etiology

1. •

   Social and genetic factors important

2. •

   Risk factors:

   1. 1.

      Broken homes

   2. 2.

      Unemployment

   3. 3.

      Divorce

   4. 4.

      Recurrent depression

   5. 5.

      Addiction to another substance, including tobacco

   6. 6.

      Working long hours (≥55 hours/week)

Diagnosis

Workup

1. •

   The USPSTF recommends that clinicians screen adults 18 years and older for alcohol misuse and provide persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse. Several screening tests (CAGE, TWEAK, CRAFFT, AUDIT-C) are available. The four-item CAGE (feeling need to Cut down, Annoyed by criticism, Guilty about drinking, and need for an Eye-opener in the morning) is the most popular screening test in primary care (Fig. E1). A positive response should lead to further questioning. The sensitivity of the CAGE ranges from 43% to 94% and its specificity ranges from 70% to 97%. The five-item TWEAK scale (Tolerance, Worry, Eye-openers, Amnesia, [K] cut down) and the TACE questionnaire (Tolerance, Annoyance, Cut down, Eye-opener) are designed to screen pregnant women for alcohol misuse. They detect lower levels of alcohol consumption that may pose risks during pregnancy. The CRAFFT questionnaire (riding in Car with someone who was drinking, using alcohol to Relax, using alcohol while Alone, Forgetfulness, criticism from Friends and Family, Trouble) is useful as a screening tool for adolescents. Its sensitivity is 92% and specificity 64% for alcohol abuse. Single-question screening about alcohol consumption in a day (“When was the last time you had more than X drinks in a day?” [where X is 5 for men and 4 for women]) with the threshold set at “in the past 3 months” is 85% sensitive and 70% specific in men and 82% and 70% in women for unhealthy alcohol use. The 3-question AUDIT-C is a shorter form of the 10-item AUDIT, and the questions center on the quantity and frequency of alcohol use. It asks how often someone has had a drink containing alcohol, how many standard drinks containing alcohol one consumes on a typical day when one is drinking, and how often one has six or more drinks on one occasion. Scoring ranges from 0 to 4 on each question with a total score range of 0 to 12. A total score of 3 or higher for women and 4 or higher for men indicates alcohol use disorder and need for further assessment. Its sensitivity ranges from 85% in Hispanic women to 95% in white men.

   

2. •

   Laboratory evaluation (see below).

Laboratory Tests

1. •

   Lab tests alone do not accurately detect alcohol problems but can help identify medical complications related to alcohol use, such as pancreatitis or cirrhosis.

2. •

   Gamma-glutamyltransferase (GGTP), generally elevated

3. •

   Liver transaminases (alanine aminotransferase [ALT], aspartate aminotransferase [AST]), often elevated, may be normal or low in advanced liver disease.

4. •

   Low albumin level, hypophosphatemia, hypomagnesemia from malnutrition

5. •

   Complete blood count (CBC) reveals elevated mean corpuscular volume from toxic effect of alcohol on erythrocyte development in nutritional deficiencies.

6. •

   Stool for occult blood may be positive as a result of gastritis or variceal bleeding

7. •

   RBC folate, vitamin B₁₂ level, vitamin B₆, vitamin B₁ level

Imaging Studies

Indicated only with a history of trauma. CT or ultrasound of abdomen may reveal fatty liver or cirrhosis in advanced stages.

Treatment

Nonpharmacologic Therapy

1. •

   Twelve-step facilitation, cognitive behavioral therapy, and motivational enhancement therapy improve the chances of recovery in patients with alcohol abuse and dependence.

2. •

   Depression, if present, should be treated at same time alcohol is withdrawn.

Acute General Rx

Alcohol withdrawal syndrome (AWS) occurs when a person stops ingesting alcohol after prolonged consumption. It can result in four possible clinical patterns depending on the severity of the patient’s alcohol abuse and the time from the patient’s previous alcohol ingestion. Fig. 2 illustrates typical symptoms depending on time course of alcohol withdrawal. Blood ethanol level decreases by ∼20 mg/dl/hr (Fig. E3) in a normal person. Although discussed separately, these withdrawal states blend together in real life. Table 1 summarizes medications for the treatment of alcohol dependence.

1. 1.

   Tremulous state (early alcohol withdrawal, “impending DTs,” “shakes,” “jitters”).

   1. a.

      Time interval: usually occurs 6 to 8 hr after the last drink or 12 to 48 hr after reduction of alcohol intake; becomes most pronounced at 24 to 36 hr.

   2. b.

      Manifestation: tremors, mild agitation, insomnia, tachycardia; symptoms are relieved by alcohol.

   3. c.

      Detoxification can be in the outpatient (ambulatory) or inpatient setting. Candidates for outpatient detoxification should have a reasonable support system (e.g., reliable contact person) who can monitor progress and lack of any significant comorbid conditions (e.g., suicide risk, seizure disorder, coexisting benzodiazepine dependence, prior unsuccessful outpatient detoxification, pregnancy, cirrhosis) or risk factors for severe withdrawal (age >40 yr, drinking >100 g of ethanol daily [e.g., 1 pint of liquor or eight 12-oz cans of beer, random blood alcohol concentration >200 mg/dl]).

   4. d.

      Inpatient treatment:

      1. (1)

         Admit to medical floor (private room); monitor vital signs q4h; institute seizure precautions; maintain adequate sedation.

      2. (2)

         Administer lorazepam as follows:

         1. (a)

            Day 1: 2 mg PO q4h while awake and not lethargic.

         2. (b)

            Day 2: 1 mg PO q4h while awake and not lethargic.

         3. (c)

            Day 3: 0.5 mg PO q4h while awake and not lethargic.

         4. (d)

            NOTE: Hold sedation for lethargy or abnormal vital or neurologic signs. The preceding doses are only guidelines; it is best to titrate the dose case by case.

      3. (3)

         In patients with mild to moderate withdrawal and without history of seizures, individualized benzodiazepine administration (rather than a fixed-dose regimen) results in lower benzodiazepine administration and avoids unnecessary sedation. The Clinical Institute Withdrawal Assessment Scale for Alcohol, Revised (CIWA-Ar) scale (Box 1) can be used to measure the severity of alcohol withdrawal. It consists of 10 items: nausea; tremor; autonomic hyperactivity; anxiety; agitation; tactile, visual, and auditory disturbances; headache; and disorientation. Each item is assigned a score from 0 to 7. For example, in the “agitation” category 0 indicates normal activity, and 7 indicates that the patient constantly thrashes about. For the category of “tremor,” 0 indicates that tremor is not present and 7 that tremor is severe, even with arms not extended. The maximum total score is 67. Patients with mild AWS symptoms (CIWA-Ar score <8) can be monitored on an outpatient basis. Benzodiazepines are beneficial for most patients with a CIWA-AR score ≥8 and are strongly recommended in patients with substantial withdrawal symptoms (CIWA-Ar score >12). Patients with CIWA-Ar score of ≥15 should be admitted to detox unit. In-patient treatment is also recommended for patients with history of withdrawal seizures and for those with suicidal ideation and significant comorbidities.

         BOX 1Alcohol Withdrawal Assessment Scoring Guidelines (Revised Clinical Institute Withdrawal Assessment for Alcohol Scale)

         Nausea and Vomiting (0-7)

         0, none; 1, mild nausea with no vomiting; 4, intermittent nausea; 7, constant nausea, frequent dry heaves and vomiting

         Tremor (0-7)

         0, no tremor; 1, not visible, but can be felt fingertip to fingertip; 4, moderate, with patient’s arms extended; 7, severe, even with arms not extended

         Paroxysmal Sweats (0-7)

         0, no sweats; 1, barely perceptible sweating, palms moist; 4, beads of sweat obvious on forehead; 7, drenching sweats

         Anxiety (0-7)

         0, no anxiety, patient at ease; 1, mildly anxious; 4, moderately anxious or guarded, so anxiety is inferred; 7, equivalent to acute panic states seen in severe delirium or acute schizophrenic reactions

         Agitation (0-7)

         0, normal activity; 1, somewhat more than normal activity; 4, moderately fidgety and restless; 7, pacing back and forth during, or constantly thrashing about

         Tactile Disturbances (0-7)

         Ask, “Have you experienced any itching, pins and needles sensation, burning or numbness, or a feeling of bugs crawling on or under your skin?”

         0, none; 1, very mild itching, pins and needles, burning, or numbness; 2, mild itching, pins and needles, burning, or numbness; 3, moderate itching, pins and needles, burning, or numbness; 4, moderately severe tactile hallucinations; 5, severe hallucinations; 6, extremely severe hallucinations; 7, continuous hallucinations

         Auditory Disturbances (0-7)

         Ask, “Are you more aware of sounds around you? Are they harsh? Do they startle you? Do you hear anything that disturbs you or that you know isn’t there?”

         0, not present; 1, very mild harshness or ability to startle; 2, mild harshness or ability to startle; 3, moderate harshness or ability to startle; 4, moderate hallucinations; 5, severe hallucinations; 6, extremely severe hallucinations; 7, continuous hallucinations

         Visual Disturbances (0-7)

         Ask, “Does the light appear to be too bright? Is its color different than normal? Does it hurt your eyes? Are you seeing anything that disturbs you?”

         0, not present; 1, very mild sensitivity to light; 2, mild sensitivity; 3, moderate sensitivity; 4, moderate hallucinations; 5, severe hallucinations; 6, extremely severe hallucinations; 7, continuous hallucinations

         Headache (0-7)

         0, not present; 1, very mild; 2, mild; 3, moderate; 4, moderately severe; 5, severe; 6, very severe; 7, extremely severe

         Orientation and Clouding of Sensorium (0-4)

         Ask, “What day is this? Where are you? Who am I?”

         0, oriented; 1, cannot do serial additions or is uncertain about date; 2, disoriented to date by no more than 2 calendar days; 3, disoriented to date by more than 2 calendar days; 4, disoriented to place and/or person

         Total Score

         1. 0 to 9: absent or minimal withdrawal

         2. 10 to 19: mild to moderate withdrawal

         3. More than 20: severe withdrawal

         From Sullivan JT, Sykora K, Schneiderman J, et al: Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). Br J Addict 84:1353-1357, 1989.

      4. (4)

         Beta-adrenergic blockers: beta-blockers are useful for controlling blood pressure and tachyarrhythmias. However, they do not prevent progression to more serious symptoms of withdrawal and, if used, should not be administered alone but in conjunction with benzodiazepines. Beta-blockers should be avoided in patients with contraindications to their use (e.g., bronchospasm, bradycardia, or severe congestive heart failure). Centrally acting alpha-adrenergic agonists such as clonidine ameliorate symptoms in patients with mild to moderate withdrawal but do not reduce delirium or seizures.

      5. (5)

         Vitamin replacement: thiamine 100 mg IV or IM for at least 5 days plus oral multivitamins. The IV administration of glucose can precipitate Wernicke’s encephalopathy in alcoholics with thiamine deficiency; therefore thiamine administration should precede IV dextrose.

      6. (6)

         Hydration PO or IV (high-caloric solution): if IV, glucose with Na⁺, K⁺, Mg²⁺, and phosphate replacement prn.

      7. (7)

         Laboratory studies.

         1. (a)

            CBC, platelet count, INR.

         2. (b)

            Electrolytes, glucose, blood urea nitrogen, creatinine.

         3. (c)

            GGTP, ALT, AST.

         4. (d)

            Phosphorus and magnesium.

         5. (e)

            Serum vitamin B₁₂ and folic acid (if megaloblastic features in blood smear).

      8. (8)

         Diagnostic imaging: generally not necessary; if subdural hematoma is suspected (evidence of trauma, persistent lethargy), a CT scan should be ordered.

      9. (9)

         Social rehabilitation: group therapy such as Alcoholics Anonymous; identification and treatment of social and family problems should be initiated during the patient’s hospital stay.

2. 2.

   Alcoholic hallucinosis:

   1. a.

      Manifestations: hallucinations usually are auditory, but hallucinations occasionally are visual, tactile, or olfactory; usually there is no clouding of sensorium as in delirium (clinical presentation may be mistaken for an acute schizophrenic episode). Disordered perceptions become most pronounced after 24 to 36 hr of abstinence.

   2. b.

      Treatment: same as for DTs (see “Withdrawal seizures”).

3. 3.

   Withdrawal seizures (“rum fits”):

   1. a.

      Time interval: usually occurs 7 to 30 hr after cessation of drinking, with a peak incidence between 13 and 24 hr.

   2. b.

      Manifestations: generalized convulsions with loss of consciousness; focal signs are usually absent; consider further investigation with CT scan of head and electroencephalography if clearly indicated (e.g., presence of focal neurologic deficits, prolonged postictal confusion state). In addition, in a febrile patient who is having a seizure or altered mental state, a lumbar puncture is necessary.

   3. c.

      Treatment:

      1. (1)

         Diazepam 2.5 mg/min IV until seizure is controlled (check for respiratory depression or hypotension) may be beneficial for prolonged seizure activity; IV lorazepam 1 to 2 mg q2h can be used in place of diazepam. Withdrawal seizures generally are self-limited and treatment is not required; the use of phenytoin or other anticonvulsants for short-term treatment of alcohol withdrawal seizures is not recommended.

      2. (2)

         Thiamine 100 mg IV, followed by IV dextrose, should also be administered.

      3. (3)

         Electrolyte imbalances (increased Mg²⁺, decreased K⁺, increased or decreased Na⁺, decreased PO₄³⁻) that may exacerbate seizures should be corrected.

4. 4.

   DTs:

   1. a.

      Time interval: variable; usually occurs within 1 wk after reduction or cessation of heavy alcohol intake and persists for 1 to 3 days. Peak incidence is 72 hr and 96 hr after the cessation of alcohol consumption.

   2. b.

      Manifestations: profound confusion, tremors, vivid visual and tactile hallucinations, autonomic hyperactivity; this is the most serious clinical presentation of alcohol withdrawal (mortality rate is approximately 15% in untreated patients).

   3. c.

      Treatment

      1. (1)

         Admission to a detoxification unit where patient can be observed closely.

      2. (2)

         Vital signs q30min (neurologic signs, if necessary).

      3. (3)

         Use of lateral decubitus or prone position if restraints are necessary.

      4. (4)

         NPO: nasogastric tube for abdominal distention may be necessary but should not be routinely used.

      5. (5)

         Laboratory studies: same as for early alcohol withdrawal.

      6. (6)

         Vigorous hydration (4 to 6 L/day): IV with glucose (Na⁺, K⁺, PO₄³⁻ and Mg²⁺ replacement [if patient has hypophosphatemia or hypomagnesemia]).

      7. (7)

         Vitamins: thiamine 100 mg IV qd. The initial dose of thiamine should precede the administration of IV dextrose; multivitamins (may be added to the hydrating solution).

      8. (8)

         Sedation: control of agitation should be achieved with rapid-acting sedative-hypnotic agents in adequate doses to maintain light somnolence for the duration of delirium.

         1. (a)

            Initially: lorazepam 2 to 5 mg IM/IV repeated prn.

         2. (b)

            Maintenance (individualized dosage): chlordiazepoxide, 50 to 100 mg PO q4-6h, lorazepam 2 mg PO q4h, or diazepam 5 to 10 mg PO tid; withhold doses or decrease subsequent doses if signs of oversedation are apparent.

         3. (c)

            Midazolam is also effective for managing DTs. Its rapid onset (sedation within 2 to 4 min of IV injection) and short duration of action (approximately 30 min) make it an ideal agent for titration in continuous infusion.

      9. (9)

         Treatment of seizures (as previously described).

      10. (10)

          Diagnosis and treatment of concomitant medical, surgical, or psychiatric conditions.

Chronic Rx

1. •

   See “Referral.”

2. •

   Pharmacotherapies for alcoholism include:

   1. 1.

      Acamprosate is a synthetic compound with a chemical structure similar to the neurotransmitter gamma-aminobutyric acid and the amino acid neuromodulator taurine. Its mechanism of action is not completely understood. It is indicated for the maintenance of abstinence from alcohol in patients with alcohol dependence who are abstinent at treatment initiation. It should be used only as part of a comprehensive psychosocial treatment program. It does not cause a disulfiram-like reaction as a result of ethanol ingestion. Dose is two 333-mg tablets tid. Treatment should be initiated as soon as possible after the period of alcohol withdrawal, when the patient has achieved abstinence, and should be maintained if the patient relapses. Avoid acamprosate if severe renal impairment is present.

   2. 2.

      The long-acting opiate antagonist naltrexone inhibits the rewarding effects of alcohol. The starting dose is 25 mg/day, increased to 50 mg PO qd after 1 wk. An extended-release, once-monthly injection of naltrexone is also available and can be used along with psychosocial support to maintain alcohol abstinence. In patients with opioid dependence, naltrexone can precipitate acute withdrawal syndrome and should not be used at least 7 days from last opioid use. There are no established guidelines on the appropriate length of naltrexone treatment for alcohol dependence. One study recommends at least 3 mo of treatment. Avoid naltrexone if acute hepatitis, hepatic failure, or ongoing opioid use is present.

   3. 3.

      Topiramate or gabapentin can be offered to patients with moderate to severe alcohol use disorder who have a goal of abstinence or reducing alcohol use.

   4. 4.

      Disulfiram (Antabuse). Dosage is 500 mg max qd for 1 to 2 wk, then 125 to 500 mg qd. It interferes with the metabolism of alcohol by inhibiting aldehyde dehydrogenase, causing an accumulation of acetaldehyde. It produces unpleasant symptoms (nausea, flushing, elevated blood pressure, headache, weakness) when alcohol is ingested. It is an older drug that is now rarely used.

   5. 5.

      Avoid pharmacological treatments in pregnant or breastfeeding women.

Disposition

See “Referral.”

Referral

1. •

   To Alcoholics Anonymous or Adult Children of Alcoholics

2. •

   Family members to Al-Anon or Al-A-Teen

3. •

   Many cities have Salvation Army Adult Rehabilitation centers; all patients accepted, regardless of ability to pay

Pearls & Considerations

Comments

1. •

   Relative indications for inpatient alcohol detoxification are as follows: history of DTs or withdrawal seizures, severe withdrawal symptoms, concomitant psychiatric or medical illness, pregnancy, multiple previous detoxifications, recent high levels of alcohol consumption, and lack of reliable support network.

2. •

   Detoxification is not a stand-alone treatment but should serve as a bridge to a formal treatment program for alcohol dependence.

3. •

   The cure rate for alcoholism is highly 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 many alcoholic beverages, please discuss it with me.” Those who do open up the discussion can be given the facts in a nonjudgmental 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.

4. •

   In a recent clinical trial, patients receiving medical management with naltrexone (100 mg/day), combined behavioral intervention (CBI), or both fared better on drinking outcomes, whereas acamprosate showed no evidence of efficacy, with or without CBI. No combination produced better efficacy than naltrexone or CBI alone in the presence of medical management.

5. •

   Accidental or intentional ingestion of methanol or ethylene glycol is more common in people with alcoholism. Fig. E4 describes a treatment algorithm for suspected toxic alcohol poisoning.

Suggested Readings

• E.J. Edelman, D.A. Fiellin: In the clinic: alcohol abuse. Ann Intern Med. 2016

• K. Fagbemi: What is the best questionnaire to screen for alcohol use disorder in an office practice?. Clev Clinic J Med. 78:649–651 2011

• P.D. Friedmann: Alcohol use in adults. N Engl J Med. 368:365–373 2013 23343065

• D.E. Jonas: Pharmacotherapy for adults with alcohol use disorders in outpatient settings: a systematic review and meta-analysis. JAMA. 311:1889–1900 2014 24825644

• V.A. Moyer: Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: US Preventive Services Task Force Recommendations Statement. Ann Intern Med. 159:210–218 2013 23698791

• H.L. Muncie: Outpatient management of alcohol withdrawal syndrome. Am Fam Phys. 88 (9):589–595 2013

• B.F. Palmer, D.J. Clegge: Electrolyte disturbances in patients with chronic alcohol use disorder. N Engl J Med. 377:1368–1377 2017 28976856

• V.I. Reus, et al.: The American Psychiatric Association practice guideline for the pharmacological treatment of patients with alcohol use disorder. Am J Psychiatry. 175:86 2018 29301420

• R. Saitz: Chronic care management for dependence on alcohol and other drugs, the AHEAD randomized trial. JAMA. 310 (11):1156–1167 2013 24045740

Related Content

1. Alcohol Abuse (Patient Information)

2. Abuse, Drug (Related Key Topic)

3. Alcoholic Hepatitis (Related Key Topic)

4. Wernicke Syndrome (Related Key Topic)