Alcoholism

Alcoholism Overview Definition Etiology Risk Factors Signs and Symptoms Differential Diagnosis Diagnosis Physical Examination Laboratory Tests Pathology/Pathophysiology Imaging Other Diagnostic Procedures Treatment Options Treatment Strategy Drug Therapies Complementary and Alternative Therapies Patient Monitoring Other Considerations Prevention Complications/Sequelae Prognosis Pregnancy References

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Overview Definition

Alcoholism has both medical and psychosocial factors. Ethanol, or primary alcohol, is a central nervous system (CNS) depressant, which decreases neuronal activity. Alcoholism, legally defined, is a concentration of at least 80 to 100 mg/dL. However, one to two drinks (i.e., 20 to 30 mg/dL) can cause psychomotor and cognitive change. Death occurs at concentrations of 300 to 400 mg/dL. The fourth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) separates substance disorders into two categories: substance use disorders (dependence, abuse) and substance-induced disorders (substance-induced intoxication, withdrawal, psychotic, or mood disorders), and defines alcoholism as lack of functioning such that "the individual continues substance use despite significant substance-related problems."

Ninety percent of people drink alcohol at some time in their life. Alcoholism affects 10% to 20% of men and 3% to 10% of women. Approximately 40% to 50% of men have temporary alcohol-induced problems, with 30% to 40% experiencing blackouts between their teens and late 20s. Alcoholism contributes to over 50% of car and industrial fatalities, drownings, and child or domestic abuse.

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Etiology

Alcoholism is caused by chronic over-consumption of alcohol. Psychological theories are not conclusive. Genetic predisposition has been shown. Neurocognitive tests have predictive value. Environmental factors may influence but do not cause alcoholism.

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Risk Factors

• Genetic
• Preexisting psychiatric disorder
• Early onset of alcohol consumption
• Stress

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Signs and Symptoms

Symptoms vary with the amount of alcohol ingested and duration of abuse.

• Adaptation to use
• Psychological, social, occupational dysfunction
• Malnutrition, anorexia
• Cardiovascular symptoms (leading cause of death)—including hypertension, arrhythmias, paroxysmal tachycardia ("holiday heart"), congestive heart failure; worsened with preexisting disease
• Increased levels of cancer (second leading cause of death)—head, neck, esophagus, liver, pancreas, cardia of the stomach, breast, lung, rectal
• Repeated infections—tuberculosis, urinary tract
• Pulmonary symptoms—complicated by smoking; respiratory failure, pneumonia
• CNS—unsteady gait or stance; cognitive impairment; psychiatric manifestations (e.g., mood, anxiety, psychotic disorders); blackouts; coma; sleep latency
• Alcohol withdrawal syndrome—6 to 24 hours after blood alcohol level drop; lasts two to seven days; ranges from nausea, tachycardia, insomnia, and anxiety to fever, hallucinations, and rarely delirium tremens
• Diarrhea, vomiting
• Gastrointestinal bleeding
• Men—increased sexual drive with concurrent decreased erectile capacity
• Women—spontaneous abortion, amenorrhea
• Pancreatitis
• Hepatitis
• Poor wound healing
• Ascites
• Swollen, painful muscles, paralysis, areflexia
• Increased bone fractures
• Hypoglycemia
• Hypothermia

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Differential Diagnosis

Alcohol-induced organ damage and disease needs to be distinguished from illnesses occurring without abuse.

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Diagnosis Physical Examination

Physical examination reveals specific organ damage (e.g, hepatomegaly, indicating liver damage) or trauma. Muscles are tender or weak. Patient may or may not appear intoxicated.

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Laboratory Tests

High-normal or elevated levels of the following are indicative of alcoholism.

• Blood alcohol
• Mean corpuscle volume
• Gamma-glutamyl transferase (GGT)
• Serum uric acid
• Carbohydrate-deficient transferin
• Creatine phosphokinase
• Serum AST and possibly ALT
• Serum bilirubin

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Pathology/Pathophysiology

• Folic acid deficiency causing hyperplastic bone marrow, reticulocytopenia, hypersegmented neutrophils
• Decreased white blood cell production causing decreased response to antigens; decreased granulocyte adherence and mobility; toxic granulocytosis
• Abnormalities in central adrenergic alpha- and beta-receptors and dopamine turnover
• Nutritional deficiencies of potassium, magnesium, zinc, calcium, phosphorous, folic acid, vitamins B1 (thiamine), B3 (niacin), B6 (pyridoxine), and vitamin A
• Hemorrhagic lesions of the duodenal villi
• Decreased water and electrolyte absorption
• Increased fatty accumulation in liver cells, cirrhosis
• Myoglobinuria
• Leukopenia

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Imaging

Imaging is used to diagnose alcohol-related diseases and to screen for repeated bone fractures.

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Other Diagnostic Procedures

Alcoholism has a low diagnostic rate.

• Take history, consulting closest family member(s)
• Perform tests for alcohol-abuse markers and nutritional deficiencies
• Screen for alcohol-related diseases
• Administer patient-completed tests (e.g., Michigan Alcohol Screening Test)
• Determine need for hospitalization

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Treatment Options Treatment Strategy

Treatment must include addressing both medical issues and rehabilitation. Rehabilitation includes the following.

• Motivate abstinence
• Psychotherapies
• Alcoholics Anonymous (or other support groups)

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Drug Therapies

• Administration of another type of CNS depressant for withdrawal symptoms and seizure prevention
• Benzodiazepines—safest CNS depressants, superior anticonvulsive; individualized dose depending on patient response, then decrease by 20% each day for three to five days (e.g., chlordiazepoxide, 25 to 50 mg every four to six hours); choose benzodiazepines with shorter half-life with liver or brain damage (e.g., lorazepam, 6 to 7 mg/day in three doses then decrease to 1 to 2 mg/day)
• Antipsychotic medications—for those not responding to benzodiazepines, no anticonvulsive properties (e.g., haloperidol, 240 mg/day; synergistic with lorazepam)
• Alcohol withdrawal syndrome—aggressive control is essential (e.g., lorazepam, 0.5 to 4.0 mg every 10 to 30 minutes intravenously); lumbar puncture and antibiotics for qualified seizure patient

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Complementary and Alternative Therapies

Psychosocial support and intervention is important. Therapists who have specific experience with alcoholism should be recommended. Several nutrients are deficient in alcoholism. Supplementation addresses deficiencies and may prevent some alcohol-induced organ damage and decrease cravings. Herbs are useful to facilitate proper liver functioning and provide symptom relief.

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Nutrition

The following nutrients are recommended.

• Vitamin A (25,000 IU/day)
• B-complex (B1 (50 to 100 mg/day), B2 (50 mg/day), B3 (25 mg/day), B5 (100 mg/day), B6 (50 to 100 mg/day), B12 (100 to 1,000 mcg/day)
• Vitamin C (1,000 mg bid to tid)
• Vitamin E (400 IU/day), cardioprotective
• Magnesium (250 mg bid) decreases withdrawal symptoms
• Selenium (200 mcg/day) protects against fatty liver
• Zinc (15 mg/day) deficiencies impair ethanol metabolism
• Chromium (250 to 500 mcg bid) helps reduce sugar cravings and helps reduce hypoglycemic-related alcohol cravings
• Amino acids: carnitine (500 mg bid) is hepatoprotective, glutamine (1 g/day) decreases cravings, glutathione (300 mg/day) protects liver and heart.

A well-balanced, nutritionally adequate diet helps to stabilize alcohol-induced dysglycemia and to decrease cravings. Eliminate simple sugars, increase complex carbohydrates, ensure adequate protein, increase essential fatty acids, and decrease saturated fats and fried foods. Avoid caffeine as it can induce hypoglycemia.

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Herbs

Herbs may be used as dried extracts (pills, capsules, or tablets), teas, or tinctures (alcohol extraction, unless otherwise noted). Dose for teas is 1 heaping tsp. herb/cup water steeped for 10 minutes (roots need 20 minutes). Herbal extracts made with alcohol should be avoided in alcoholics.

• Milk thistle (Silybum marianum): 80 to 200 mg tid is hepatoprotective, treats alcohol-induced fatty liver and cirrhosis.
• Dandelion (Taraxacum officinale): 2 to 8 g of root tid as decoction or infusion, or 5 ml tid of leaf tincture is a diuretic and liver detoxifier. Works well with milk thistle.
• Kudzu (Pueraria lobata) reduces cravings.
• Skullcap (Scutellaria lateriflora): historic use for hysteria, tension, and nervous disorders, especially anxiety; a cup of tea before bed can help insomnia.
• Dessicated liver capsules (500 mg tid) help heal liver tissue.

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Homeopathy

An experienced homeopath would consider an individual's constitutional type to prescribe a more specific remedy and potency. Some of the most common acute remedies are listed below. Acute dose is three to five pellets of 12X to 30C every one to four hours until symptoms resolve.

• Arsenicum album for anxious, compulsive people, with nausea, vomiting, and diarrhea
• Nux vomica for irritability and compulsiveness with constipation, nausea, and vomiting
• Lachesis for cravings for alcohol, headaches, and difficulty swallowing
• Lycopodium for low self-esteem, heartburn, impotence

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Acupuncture

May be very helpful at decreasing cravings and increasing recovery. It can also be helpful for liver repair, reducing anxiety and depression, and alleviating tremors and fatigue associated with alcohol withdrawal. Acupuncture is helpful in maintaining sobriety.

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Patient Monitoring

After emergent care, follow-up should continue for 6 to 12 months.

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Other Considerations Prevention

The best prevention is abstinence. With little evidence for efficacy, disulfiram (250 mg/day) is often prescribed for prevention. Two promising anticraving drugs are naltrexone and acamprosate.

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Complications/Sequelae

• Wernicke-Korsakoff syndrome—symptoms may occur together; Wernicke's encephalopathy (ataxia of gait, confusion, nystagmus, ophthalmoplegia), usually acute and reversible; Korsakoff's (severe amnesia—both anterograde and retrograde), reversible in 20% of patients
• Mallory-Weiss lesion—tear in the mucosa at gastroesophageal junction from repeated, violent vomiting
• Irreversible testicular atrophy—loss of sperm cells

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Prognosis

About a fifth of alcoholics permanently abstain. The course of illness includes periods of remission followed by periods of abuse. Life expectancy is decreased by about 15 years.

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Pregnancy

Abstinence from alcohol is the only completely safe measure during pregnancy.

• Ethanol rapidly transfers to the placenta, causing permanent fetal damage, fetal death, and abortion
• Fetal alcohol syndrome may result in mental retardation, cardiac defects, growth deficiencies, poor coordination, facial changes (e.g., epicanthic folds, flat-bridged nose)

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References

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association; 1994.

Bartram T. Encyclopedia of Herbal Medicine. Dorset, England: Grace Publishers;1995:13.

Dambro MR. Griffith's 5-Minute Clinical Consult. 1999 ed. Baltimore, Md: Lippincott Williams & Wilkins, Inc.: 1999.

Fauci AS, Braunwald E, Isselbacher KJ, et al, eds. Harrison's Principles of Internal Medicine. 14th ed. New York, NY: McGraw-Hill; 1998.

Gruenwald J, Brendler T, Jaenicke C, et al, eds. PDR for Herbal Medicines. Montvale, NJ: Medical Economics Company; 1998:1128-1129.

Goroll A, ed. Primary Care Medicine. 3rd ed. Philadelphia, Pa: Lippincott-Raven Publishers; 1995.

Johnson JL, Leff M. Children of substance abusers: overview of research findings. Pediatrics. 1999;103(5).

Kaplan HW, ed Comprehensive Textbook of Psychiatry. 6th ed. Baltimore, Md: Williams & Wilkins; 1995.

Morrison R. Desktop Guide to Keynotes and Confirmatory Symptoms. Albany, Calif: Hahnemann Clinic Publishing; 1993:39-44, 272-276, 215-218.

Murray MT, Pizzorno JE. Encyclopedia of Natural Medicine. 2nd ed. Rocklin, Calif: Prima Publishing; 1998:122-127.

Rosen P, ed. Emergency Medicine: Concepts and Clinical Management. 4th ed. St. Louis, Mo: Mosby-Year Book; 1998.

Werbach M. Nutritional Influences on Illness. New Canaan, Conn: Keats Publishing Inc; 1987:11-22.

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