Alcohol Abuse

Aka: Alcohol Abuse, Alcohol Dependence, Alcoholism, Problem Drinking, Alcohol Use Disorder, Alcoholism Complications, Vitamin Deficiency in Alcoholism

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II. Epidemiology: General

  1. Prevalence
    1. Alcohol Dependence: 8-14% lifetime
    2. Alcohol Use Disorder: 29% lifetime (14% one year), 14.5 Million in U.S. as of 2022
  2. Age of symptom onset: 15 to to 19 years
  3. Familial predisposition in Autosomal Dominant pattern

III. Epidemiology: Alcohol Impaired Driving

  1. Alcohol Impaired Driving Survey (n=102,263)
    1. Overall alcohol Impaired Driving in last month: 2.5%
    2. Lowest rate: Women over age 55 years old (0.1%)
  2. Predictors of alcohol Impaired Driving
    1. Men aged 21 to 34 years: 7%
    2. Over 4 Alcoholic drinks on 1 occasion in last month
    3. Greater than two Alcoholic drinks per day
  3. States of highest alcohol Impaired Driving
    1. Alaska
    2. Nevada
    3. Wisconsin
    4. Michigan
    5. North Dakota
  4. References
    1. Liu (1997) JAMA 277:122-5 [PubMed]

IV. History: Famous Alcoholics

  1. Sinclair Lewis
  2. Edgar Allen Poe
  3. Dylan Thomas
  4. F. Scott Fitzgerald
  5. Jim Thorpe

V. Pathophysiology

  1. See Addiction Pathophysiology
  2. Substance Abuse or Alcoholism Definition Criteria
    1. Compulsion-Preoccupation
    2. Use despite adverse consequences
    3. Loss of Control
    4. Denial
  3. Mechanism
    1. Alcohol increases activity at GABA Receptors with secondary CNS depression
      1. Chronic Alcohol use down regulates GABA Receptors and up regulation of NMDA receptors
      2. Alcohol Withdrawal results in excessive excitation
    2. Limbic System drive state
    3. Alcoholics have lower level of endogenous endorphins
      1. Need TIQs externally from Alcohol to feel normal
  4. Other preparation misued for their Alcohol content
    1. Mouthwash
    2. Vanilla extract
    3. Ethanol-based hand sanitizer (especially in health care centers)
      1. Small ingestions of hand sanitizer can cause significant Alcohol Intoxication (>60% Alcohol)
      2. Some users extract the Alcohol content with salt

VI. Physiology: Alcohol Digestion Pathway

  1. One ounce Alcohol takes 1 hour, mouth to excretion
  2. No Digestion required before absorption
  3. Small amount absorbed in Stomach
  4. Most Alcohol absorbed in Small Intestine (duodenum)
  5. Metabolism
    1. Alcohol converted to acetaldehyde
    2. Acetaldehyde converted in liver to acetic acid
  6. Excretion
    1. Renal excretion: 10%
    2. Hepatic excretion: 90%

VII. History

  1. See Alcoholism Screening
    1. AUDIT-C (or full AUDIT tool, or single question screening)
    2. CAGE Questions
    3. NIAAA Quantity and Frequency Questionnaire
  2. See Alcohol Use Disorder Diagnosis
    1. Alcohol Use Disorder integrates Alcohol Abuse and dependence into a single diagnosis
  3. See Substance Abuse Evaluation
  4. See medical complications and comorbid conditions below
  5. Alcohol use history (See Grading Alcohol Use)
    1. Drinks per day
      1. Men: >2 per day (>14/week) suggests Alcohol Dependence
      2. Women: >1 per day (>7/week) suggests Alcohol Dependence
    2. Last drink
    3. Binge drinking
      1. Men: >5 drinks on single occasion in last year suggests Alcohol Dependence
      2. Women: >4 drinks on single occasion in last year suggests Alcohol Dependence
  6. Other Illicit Drug use
    1. Marijuana
    2. Cocaine
    3. Heroin
    4. Amphetamines
    5. Benzodiazepine Abuse
    6. Barbiturate Abuse
    7. Quaalude
    8. Hallucinogen
  7. Prior attempts at cessation
    1. Greatest duration of sobriety
    2. Trials of cold turkey
    3. Rehabilitation Programs
    4. Detox Center Admissions
  8. Overuse Complications
    1. Blackouts
    2. Seizures
    3. Hangovers
  9. Accidents
    1. Motor Vehicle Accidents
    2. Driving while intoxicated (DUI or DWI)
  10. Injuries
    1. Frequent falls or minor Trauma
    2. Burns
    3. Violence
  11. Withdrawal complications
    1. See Alcohol Withdrawal
    2. Hallucinations
    3. Delirium Tremens (DT's)
    4. Grand Mal Seizures (GTCS)

VIII. Evaluation

  1. See Alcoholism Screening
  2. See Substance Abuse Evaluation
  3. See Skin changes suggestive of chemical dependency
  4. See Eye Examination Signs of Chemical Dependency

IX. Labs

  1. See Substance Abuse Evaluation
  2. Increased Blood Alcohol Level or Breathalyzer
  3. See Biomarkers of Alcohol Use
  4. Toxicology Screening for other drug use
  5. Complete Blood Count with increased MCV
    1. Non-megaloblastic Macrocytic Anemia
  6. Lipid panel
    1. Low High Density Lipoprotein
    2. High Triglycerides
  7. Monitoring (labs correlating with increased use)
    1. Gamma glutamyl transferase (GGT)
    2. Carbohydrate-deficient Transferrin
      1. Limited availability
    3. Phosphatidylethanol (PEth)
      1. Detectable for up to 4 weeks after Alcohol use
      2. PEth >= 20 ng/ml is associated with moderate to heavy Alcohol use
      3. Ulwelling (2018) J Forensic Sci 63(6): 1634-40 [PubMed]
      4. Kechagias (2015) Alcohol Alcohol 50(4): 399-406 [PubMed]
      5. Schrock (2017) Drug Alcohol Depend 178:80-6 [PubMed]
  8. Liver Function Tests
    1. Alkaline Phosphatase
    2. Alanine Aminotransferase (ALT, SGPT)
    3. Aspartate Aminotransferase (AST, SGOT)

X. Comorbid Conditions: Psychiatric Illness

  1. Mood Disorder
    1. Major Depression
    2. Anxiety
      1. Generalized Anxiety Disorder
      2. Panic Attacks
      3. Agoraphobia
      4. Social Phobia
    3. Bipolar Disorder
  2. Schizophrenia
  3. Borderline Personality Disorder
  4. Antisocial Personality Disorder
  5. Other Drug Abuse
    1. Tobacco Abuse: >1 pack per day in 70% of Alcoholics
  6. Post-Traumatic Stress Disorder (Veterans)

XI. Comorbid Conditions: Infectious disease

  1. Tuberculosis
  2. AIDS
  3. Viral Hepatitis

XII. Complications: Medical

  1. Korsakoff's Disease
  2. Alcoholic Hepatitis
  3. Cirrhosis
  4. Pancreatitis
  5. Esophageal Varices
  6. Macrocytic Anemia
  7. Peptic Ulcer Disease
  8. Fetal Alcohol Syndrome (children of female Alcoholics)

XIII. Complications: Vitamin Deficiency

  1. Vitamin A Deficiency (Retinol Deficiency)
    1. Presents with night blindness
  2. Vitamin C Deficiency (Scurvy)
    1. Presents with Bleeding Gums, Fatigue
  3. Vitamin B1 Deficiency (Thiamine deficiency, Wernicke's Encephalopathy)
    1. Presents with Ataxia, Confusion, Ophthalmoplegia (lateral Gaze Palsy)
  4. Vitamin B3 Deficiency (Niacin Deficiency, Pellegra)
    1. Presents with Diarrhea, dermatitis and Dementia (3 D's)
  5. Vitamin B6 Deficiency (Pyridoxine deficiency)
    1. Presents with Glossitis, Peripheral Neuropathy
  6. Vitamin B9 Deficiency (Folic Acid Deficiency)
    1. Presents with Macrocytic Anemia (also caused by B12 Deficiency)
  7. Vitamin B12 Deficiency (Cobalamin Deficiency, Pernicious Anemia)
    1. Presents with weakness, Peripheral Neuropathy, Ataxia, Dementia, macroyctic Anemia
  8. References
    1. Jhun et al. in Herbert (2016) EM:Rap 16(9): 8-10

XIV. Management

  1. See Alcohol Dependence Management
  2. See Alcohol Withdrawal
  3. See Substance Addiction Aftercare

XV. Prognosis: Relapse after CD treatment

  1. Relapse after Treatment in first 3 months: 50%
  2. Relapse after treatment in first 6 months: 80%
  3. Remain sober with Alcoholics Anonymous > 1 year: 76%

XVI. Resources

  1. See Chemical Dependency Resources
  2. Alcoholics Anonymous
    1. http://www.aa.org/
  3. Al-Anon/Ala-Teen (Family and Friends of Alcoholics)
    1. http://www.al-anon.org/
  4. Information from your Family Doctor: Alcohol Abuse
    1. http://www.familydoctor.org/healthfacts/006
  5. Rethinking Drinking (NIH)
    1. https://www.rethinkingdrinking.niaaa.nih.gov/

XVII. References

  1. Beddingfeld (July, 1996) Hospital Physician 27-39
  2. (1994) Am Fam Physician 50(8):1737-40 [PubMed]
  3. Blondell (1996) Postgrad Med 100(1):69-80 [PubMed]
  4. Chang (1995) Am Fam Physician 52(8): 2267-73 [PubMed]
  5. Enoch (2002) Am Fam Physician 65(3):441-8 [PubMed]
  6. Figueredo (1997) Postgrad Med 101(2):165-76 [PubMed]
  7. Gearhart (1991) Am Fam Physician 44(3):907-13 [PubMed]
  8. Tobias (1989) Postgrad Med 86(4):67-79 [PubMed]
  9. Winslow (2016) Am Fam Physician 93(6): 457-65 [PubMed]

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