ALCOHOL USE DISORDERS

ALCOHOL USE DISORDERS - Geninne Zinner, RNCS, ANP
BASICS
DESCRIPTION
• Any pattern of alcohol use causing significant physical, mental, or social dysfunction; key features are tolerance, withdrawal, and persistent use despite problems.
• Alcohol abuse: Maladaptive pattern of alcohol use manifested by 1 (or more) of
- Failure to fulfill obligations at work, school, or home
- Recurrent use in hazardous situations
- Recurrent alcohol-related legal problems
- Continued use despite related social or interpersonal problems
• Alcohol dependence: Maladaptive pattern of use manifested by 3 (or more) of the following
- Tolerance
- Withdrawal
- Using more than intended
- Persistent desire or attempts to cut down/stop
- Significant amount of time obtaining, using, or recovering from alcohol
- Social, occupational, or recreational activities sacrificed for alcohol use
- Continued use despite physical or psychological problems
• National Institute on Alcohol Abuse and Alcoholism (NIAAA) criteria for "at risk" drinking: Men >14 drinks a week, or >4 per occasion. Women: >7 drinks a week, or >3 per occasion.
• System(s) Affected: Nervous; Gastrointestinal
• Synonym(s): Alcoholism; Alcohol abuse; Alcohol dependence
ALERT
Geriatric Considerations
• Common in elderly; less likely to report problem. May exacerbate normal age-related cognitive deficits and disabilities.
• Multiple drug interactions
• Signs and symptoms may be different or attributed to chronic medical problem or dementia.
• Assessment tools may be inappropriate.
Pediatric Considerations
• Children of alcoholics at high risk
• In 2004, 28% of persons 12-20 years reported use in past month, 1 in 5 binge drink; binge drinkers are 7 more likely to report illicit drug use.
• Negative effect on maturation and development
• Early drinkers are 4 times more likely to develop a problem than those who begin >21.
• Depression, suicidal or disorderly behavior, family disruption, violence or destruction of property, poor school or work performance, sexual promiscuity, social immaturity, lack of interests, isolation, moodiness
Pregnancy Considerations
• Alcohol is teratogenic, especially during the 1st trimester; women should abstain during conception.
• 10-50% of children born to women who are heavy drinkers will have fetal alcohol syndrome.
• Women experience harmful effects at lower levels, and are less likely to report problems.
GENERAL PREVENTION
Counsel with family history and risk factors.
EPIDEMIOLOGY
• Predominant age: 18-25, but all ages affected
• Predominant sex: Male > Female (3:1)
Prevalence
• Lifetime prevalence: 13.6%
• 20% in primary care setting
• 48.2% of 21-year-olds in the US reported binge drinking in 2004.
RISK FACTORS
Family history, depression (40% with comorbid alcohol abuse), anxiety, other substance abuse, tobacco, male gender, low socioeconomic status, unemployment, peer/social approval, family dysfunction or trauma, PTSD, antisocial personality disorder, bipolar disorder, eating disorders, criminal involvement
Genetics
50-60% of risk is genetic.
PATHOPHYSIOLOGY
• Alcohol is a central nervous system depressant by facilitating -aminobutyric acid (GABA) inhibition and blocking N-methyl-D-aspartate receptors.
• Once tolerance has occurred, abrupt withdrawal results in hyperexcitability of these pathways.
ETIOLOGY
Multifactorial: Genetic, environment, psychosocial
ASSOCIATED CONDITIONS
• Cardiomyopathy
• Atrial fibrillation
• Hypertension
• PUD/gastritis
• Cirrhosis
• Fatty liver
• Cholelithiasis
• Hepatitis
• Diabetes mellitus
• Pancreatitis
• Malnutrition
• Upper GI malignancies
• Peripheral neuropathy
• Seizures
• Abuse
• Violence
• Trauma (falls, MVAs)


DIAGNOSIS
SIGNS AND SYMPTOMS
• Behavioral
- Anxiety, depression, insomnia;
- Visual, auditory, tactile hallucinations 12-72 hours after last drink
- Psychological and social dysfunction marital problems
- Social isolation/withdrawal
- Domestic violence
- Alcohol-related legal problems
- Repeated attempts to stop/reduce
- Loss of interest in nondrinking activities
- Employment problems (tardiness, absenteeism, decreased productivity, interpersonal problems, frequent job loss)
- Blackouts
- Complaints about alcohol-related behavior
- Frequent trauma, MVAs, ED visits.
• Physical
- Anorexia
- Nausea, vomiting
- Abdominal pain
- Palpitations
- Headache
- Impotence
- Menstrual irregularities
- Infertility
Physical Exam
• General: Fever, agitation, diaphoresis
• HEENT: Plethoric, rhinophyma, poor oral hygiene, oropharyngeal malignancies
• Cardiovascular: Hypertension, dilated cardiomyopathy, tachycardia
• Respiratory: Aspiration pneumonia
• Gastrointestinal: Stigmata of chronic liver disease, peptic ulcer disease, pancreatitis, esophageal malignancies, varices
• Genitourinary: Testicular atrophy
• Musculoskeletal: Unhealed fractures, myopathy, osteopenia, bone marrow suppression
• Neurologic: Tremors, cognitive deficits (e.g., memory impairment), peripheral neuropathy, Wernicke-Korsakoff syndrome, grand mal seizures 2-48 hours after last drink, delirium tremens (DTs) begin 48-72 hours after last drink
• Endocrine/metabolic: Hyperlipidemias, cushingoid appearance, gynecomastia
• Dermatologic: Burns (e.g., cigarettes), bruises, poor hygiene, palmar erythema, spider telangiectasias, caput medusa, jaundice
• Physical exam may be completely normal
• Withdrawal symptoms begin 4-12 hours after alcohol is stopped/reduced; peak in intensity on day 2 of abstinence; and are mostly resolved by 4th or 5th day
TESTS
• CAGE Questionnaire: (Cut down, Annoyed, Guilty, and Eye opener): More than 2 "yes" answers is 74-89% sensitive, 79-95% specific for alcohol use disorder; less sensitive for early problem drinking, or heavy drinking (1)[A]
• Alcohol Use Disorders Identification Test: 10 items, if >4: 70-92% sensitive (1)[A]
• "Had 5 or more drinks on any 1 occasion in last 3 months" sensitive screen for problem drinking
Lab
• Blood alcohol concentration
- >100 mg/dL in outpatient setting
- >150 mg/dL without obvious signs of intoxication
- >300 mg/dL at any time
• Levels suggestive if increased
- AST/ALT ratio >2.0
- -Glutamyl transferase (GGT)
- Mean corpuscular volume
- Prothrombin time
- Uric acid
- Triglycerides
- Cholesterol (total)
• Often decreased
- Calcium, magnesium, potassium, phosphorus
- Blood urea nitrogen (BUN)
- Hemoglobin, hematocrit
- Platelet count
- Serum protein, albumin
Imaging
• Radiograph: Multiple old rib fractures
• CT scan, MRI of brain: Cortical atrophy, lesions in thalamic nucleus and basal forebrain
Pathological Findings
• Liver: Inflammation or fatty infiltration (alcoholic hepatitis), periportal fibrosis (alcoholic cirrhosis occurs in only 10-20% of alcoholics)
• Gastric mucosa: Inflammation, ulceration
• Pancreas: Inflammation, liquefaction necrosis
• Heart: Dilated cardiomyopathy
• Immune system: Decreased granulocytes
• Endocrine organs: Elevated cortisol levels, testicular atrophy, decreased female hormones
• Brain: Cortical atrophy, enlarged ventricles
DIFFERENTIAL DIAGNOSIS
• Other substance use disorders
• Depression
• Dementia
• Cerebellar ataxia
• CVA
• Benign essential tremor
• Seizure disorder
• Hypoglycemia
• Diabetic ketoacidosis
• Viral hepatitis
TREATMENT
PRE-HOSPITAL
• Assess medical and psychiatric condition.
• Assess severity of withdrawal.
STABILIZATION
• Airways, breathing, circulation
• Short-acting benzodiazepine for seizure
• Correct electrolyte imbalances, acidosis
GENERAL MEASURES
• Brief interventions by primary care physicians are highly effective for problem drinking (1)[A].
• Involve family, if feasible.
• Treat comorbid problems (sleep, anxiety, etc.); use caution if prescribing medications with cross-tolerance to alcohol (benzodiazepine).
Activity
Fall preventions or restrictions if delirious
Nursing
• Frequent vital signs during acute withdrawal
• Clinical Institute Withdrawal Assessment Scale for Alcohol (CIWA-Ar) very helpful (2,3)[A].
IV Fluids
Maintain fluids during withdrawal.
MEDICATION (DRUGS)
First Line
• Symptom-triggered regimens (benzodiazepine given only when CIWA-Ar score > 8) result in less total medication given and shorter duration of treatment than fixed-dose regimens (2,3)[A].
• In fixed-dose regimens, 1st dose of benzodiazepine should achieve sedation without respiratory compromise; drugs then are tapered daily as long as withdrawal symptoms are stable; CIWA-Ar is often used to guide dosing.
• Benzodiazepines reduce incidence of DTs and seizures (2,3)[A].
- Chlordiazepoxide 50-100 mg PO/IM q6-8h, then taper (2-4)[A]
- Diazepam 5-20 mg q6-8h (2-4)[A]
- Lorazepam 1-4 mg q2-6h (2,3)[A]; in elderly, severe liver disease, or IV drip
- Phenobarbital 60-120 mg q6-8h (4)[B] may be safer during pregnancy.
- Carbamazepine 200 mg PO q.i.d., then taper over 5-7 days (efficacious for mild-moderate withdrawal, and is less sedating) (2)[A].
• Adjuncts to detoxification
- -Blockers for tachycardia or comorbid coronary artery disease (3)[B]
- Clonidine 0.1-0.2 mg PO t.i.d. for autonomic hyperactivity (3,4)[C]
- Antipsychotics for psychosis, agitation; haloperidol lowers seizure threshold (3)[C]
• Adjuncts to rehabilitation
- Naltrexone 50-100 mg PO daily, or 380 mg IM once every 4 weeks: Opiate antagonist reduces craving and chance relapse (5)[A].
- Acamprosate (Campral) 666 mg PO t.i.d. beginning after completion of withdrawal; reduces relapse of drinking (5)[A]
- Topiramate (Topamax) 25-300 mg PO daily or divided b.i.d.; enhances abstinence (3)[B]
• Supplements to all
- Thiamine 100 mg daily (1st dose IV prior to glucose to avoid Wernicke encephalopathy)
- Folic acid 1 mg daily
- Multivitamin daily
- Magnesium sulfate 1 g IM/IV q4-6h (if history of DTs or seizure) (2)[C]
• Contraindications
- Naltrexone: Pregnancy, hepatitis, hepatic failure. Monitor liver function tests.
• Precautions: Organic pain, organic brain syndromes
• Significant possible interactions: Alcohol, sedatives, hypnotics
Second Line
• Anticonvulsants gabapentin (Neurontin) and vigabatrin (Sabril) studied for detoxification (3)[B]
• Disulfiram 250-500 mg PO daily: Unproven efficacy; may provide psychologic deterrent
• Selective serotonin reuptake inhibitors (SSRIs) may be beneficial if comorbid depression exists.
FOLLOW-UP
DISPOSITION
Admission Criteria
Severe withdrawal symptoms (CIWA-Ar >14), prior DTs, withdrawal seizures, suicidal ideation or psychiatric symptoms, obstacles to follow-up, pregnancy, unstable living situation
Issues for Referral
Addiction specialist: 12-step or long-term program
PROGNOSIS
• Chronic relapsing disease; mortality rate > twice general population, death 10-15 years earlier
• Abstinence benefits survival, mental health, family, employment
• 12-step programs, cognitive-behavior and motivational therapies are effective during 1st year following treatment (1)[B].
COMPLICATIONS
• Cirrhosis
• GI malignancies
• Neuropathy
• Dementia
• Wernicke-Korsakoff syndrome
• CVA
• Ketoacidosis
• Infection
• Relapse
• Depression
• Suicide
• Trauma
PATIENT MONITORING
• Outpatient detoxification: Daily visits
• Early outpatient rehabilitation: Weekly visits
• Detoxification alone is not sufficient.
REFERENCES
1. Enoch MA, Goldman D. Problem drinking and alcoholism: Diagnosis and treatment. Amer Fam Phys. 2002;65:441-448.
2. Asplund CA, Aaronson JW, Aaronson HE. Three regimens for alcohol withdrawal and detoxification. J Fam Pract. 2004;53:545-554.
3. Bayard M, McIntyre J, Hill KR, et al. Alcohol withdrawal syndrome. Amer Fam Phys. 2004;69(pt 6):1443-1450.
4. Kosten TR, O'Connor PG. Management of drug and alcohol withdrawal. N Engl J Med. 2003;348:1786-1795.
5. Saitz R. Clinical practice. Unhealthy alcohol use. N Engl J Med. 2005;352-396.
6. Williams SH. Medications for treating alcohol dependence. Amer Fam Phys. 2005;72(pt 9):1775-1780.
ADDITIONAL READING
• Substance Abuse and Mental Health Services Administration. (NSDUH series H-27, DHHS Publication No. SMA 05-4061). 2005. (http://oas.samhsa.gov/prevalence.htm)
• National Institute on Alcohol Abuse and Alcoholism: (NIH Publication No. 00-1583). 2000. (http://pubs.niaaa.nih.gov/publications/10report/intro.pdf)
• National Council on Alcoholism and Drug Dependence. NCADD Fact Sheet. Available online: ncadd.org/pubs/fsproblems.html