Alcohol dependence

How common is alcohol abuse?

In 2012, 51.3% of adults 18 years of age and over in the United States were current regular drinkers (at least 12 drinks in the past year) and 12.9% were current infrequent drinkers (1-11 drinks in the past year).
Men are more likely to report heavy alcohol use (binge drinking for 5 or more of the past 30 days) than women, 9.3% to 3.2%.
The percentages of those aged 12 or older who were current heavy alcohol users were 7.1% of non-Hispanic whites, 4.5% of African Americans, 9.2% of American Indian or Alaska Natives, 4.6% of Native Hawaiian or Other Pacific Islanders, 2.0% of Asians, 5.8% of people reporting two or more races, and 5.1% of Hispanics.
Only 8.9% of people aged 12 or older who needed treatment for alcohol use actually received specialty treatment for their alcohol use problem. It is estimated that only 10% to 20% of patients undergoing alcohol withdrawal are treated as inpatients, so it is possible that as many as 2 million Americans may experience symptoms of alcohol withdrawal conditions each year.
There are approximately 88,000 deaths attributable to excessive alcohol use each year in the United States. Excessive alcohol use is the 3rd leading lifestyle-related cause of death for the Americans; responsible for 2.5 million years of potential life lost (YPLL) annually, or an average of about 30 years of potential life lost for each death. The economic costs of excessive alcohol consumption in 2010 were estimated at $249 billion.

Graph below shows the alcohol use among American adults.

How is alcohol use classified?

  1. No use
  2. Low risk use
  3. Hazardous drinking
  4. Alcohol abuse
  5. Alcohol dependence

 

Note:

“Low risk” is not “no risk.” Even within these limits, drinkers can have problems if they
drink too quickly, have health problems, or are older (both men and women over 65 are
generally advised to have no more than 3 drinks on any day and 7 per week). Based on
your health and how alcohol affects you, you may need to drink less or not at all.

 

It makes a difference both how much you drink on any day and how often you have
a “heavy drinking day”—that is, more than 4 drinks in a day for men or more than 3
drinks for women. The more drinks in a day and the more heavy drinking days over
time, the greater the chances for problems.

What are the health risks related to drinking alcohol?

Regular and heavy drinking damages brain, liver, kidneys, stomach, pancreas, heart and nervous system and is linked to several cancers such as breast, colon, prostate, and bladder.

Brain imaging studies have found that excessive alcohol use can cause structural and functional abnormalities of the brain. In a study by de Bruin and colleagues (2005) they showed that moderate drinkers (those with a current alcohol intake of approximately three drinks per week) had no changes to their brain size. But, Harper et al (1988) had found that men drinking more than eight standard drinks per day had changes to their brain size.

The following are some detailed information about alcohol related health issues.

Short-Term Health Risks

Excessive alcohol use has immediate effects that are most often the result of binge drinking and include the following:

  • Injuries:
    • Increased risk of traffic injuries, falls, drowning, burns and unintentional firearm injuries
  • Violence:
    • Increased intimate partner violence, child maltreatment and neglect
  • Risky sexual behaviors
    • Increased risk of unprotected sex, sex with multiple partners, sexual assault, unintended pregnancy or sexually transmitted diseases
  • Increased risk of miscarriage and stillbirth among pregnant women, and a combination of physical and mental birth defects among children that last throughout life.
  • Partner abuse
  • Violence and crime
  • Increased workplace absenteeism
  • Poor academic or occupational performance
  • Unemployment and losing job
  • Financial losses, poverty and homelessness

Long-Term Health Risks

  • Long-term excessive alcohol use can lead to the development of chronic diseases, neurological impairments and social problems:
    • Neurological conditions:
      • Stroke
      • Alcohol related dementia
      • Neuropathy
      • Wernicke-Korsakoffs syndrome
    • Cardiovascular problems:
      • Myocardial infarction
      • Heart disease and heart failure
      • Atrial fibrillation
      • Hypertension
    • Psychiatric problems:
      • Depression
      • Anxiety
      • Suicide
    • Social problems:
      • Unemployment
      • Lost productivity
      • Family problems
    • Liver diseases:
      • Alcoholic hepatitis.
      • Cirrhosis, which is among the 15 leading causes of all deaths in the United States
    • Gastrointestinal:
      • Oral cancer
      • Esophageal irritation
      • Esophageal cancer
      • Stomach inflammation
      • Stomach cancer
      • Colon cancer
    • Cancers:
      • Breast
      • Prostate
      • Bladder
    • Sex organs:
      • Decrease erectile capacity
      • Testicular atrophy
      • Irregular periods
      • Decreased ovarian size
      • Infertility and spontaneous abortions
    • Other:
      • Fetal alcohol syndrome
      • Alcoholic myopathy
      • Osteonecrosis with increased fractures and avascular necrosis of the femoral heads
      • Modest reversible decreases in thyroid hormones T3 & T4

How does alcohol work in brain?

  • The brain maintains neurochemical balance through inhibitory and excitatory neurotransmitters.
  • The main inhibitory neurotransmitter is γ-amino-butyric acid (GABA), which acts through the GABA-alpha (GABA-A) neuroreceptor.
  • One of the major excitatory neurotransmitters is glutamate, which acts through the N-methyl-D-aspartate (NMDA) neuroreceptor.
  • Alcohol enhances the effect of GABA on GABA-A neuroreceptors, resulting in decreased overall brain excitability.
  • Chronic exposure to alcohol results in a compensatory decrease of GABA-A neuroreceptor response to GABA, evidenced by increasing tolerance of the effects of alcohol.
  • Alcohol inhibits NMDA neuroreceptors, and chronic alcohol exposure results in up-regulation of these receptors. Abrupt cessation of alcohol exposure results in brain hyperexcitability, because receptors previously inhibited by alcohol are no longer inhibited. Brain hyperexcitability manifests clinically as anxiety, irritability, agitation, and tremors. Severe manifestations include alcohol withdrawal seizures and delirium tremens.

What is Kindling?

  • Kindeling is an important concept in both alcohol craving and alcohol withdrawal
  • It refers to long-term changes that occur in neurons after repeated detoxifications.
  • Recurrent detoxifications are postulated to increase obsessive thoughts or alcohol craving
  • Kindling explains the observation that subsequent episodes of alcohol withdrawal tend to progressively worsen.
  • Although the significance of kindling in alcohol withdrawal is debated, this phenomenon may be important in the selection of medications to treat withdrawal.
  • If certain medications decrease the kindling effect, they may become preferred agents.

Why should I stop drinking?

If you are at risk drinker or heavy drinker you should consider stopping drinking.

It’s up to you!

It’s up to you as to whether and when to change your drinking. Other people may be able to help, but in the end it’s your decision. Weighing your pros and cons can help. you to make the right decision.

Pros: What are some reasons why you might want to make a change and stop drinking?

  1. to improve my health
  2. to improve my relationships
  3. to avoid hangovers
  4. to do better at work or school
  5. to lose weight or get fit
  6. to save money
  7. To prevent cancer development (mouth, esophagus, stomach, intestine, pancreas, breast, colon, prostate, ovary, …)
  8. To avoid getting heart diseases
  9. to avoid more serious problems
  10. to meet my own personal standards
  11. to improve my mental health and well being
  12. to improve my emotional Health

 

Cons:

  1. Will feel more anxious
  2. Will have difficulty sleeping
  3. Others: ………….

To cut down or to quit drinking?

If you’re considering changing your drinking, you’ll need to decide whether to cut down or to quit. It’s a good idea to discuss different options with an addiction specialist. Quitting is strongly advised if you

  • try cutting down but cannot stay within the limits you set
  • have had an alcohol use disorder or now have symptoms (see page 6)
  • have a physical or mental condition that is caused or worsened by drinking
  • are taking a medication that interacts with alcohol
  • are or may become pregnant

 

If you do not have any of these conditions, talk with an addiction specialist to determine whether you should cut down or quit based on factors such as

  • family history of alcohol problems
  • your age
  • whether you’ve had drinking-related injuries
  • symptoms such as sleep disorders and sexual dysfunction

What are the diagnostic Criteria for Alcohol Withdrawal?

  • Two (or more) of the following, developing within several hours to a few days after following criterion:
    • Autonomic hyperactivity (e.g., sweating or pulse rate greater than 100 beats per minute)
    • Increased hand tremor
    • Sleeping problems
    • Nausea or vomiting
    • Transient visual, tactile, or auditory hallucination s or illusions
    • Psychomotor agitation
    • Anxiety
    • Grand mal seizures
  • The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning and the symptoms are not due to a general medical condition and are not better accounted for by another mental disorder.

What symptoms one might experience during withdrawal from alcohol?

Generally, the symptoms of alcohol withdrawal relate proportionately to the amount of alcoholic intake and the duration of a patient’s recent drinking habit. Minor withdrawal symptoms can occur while the patient still has a measurable blood alcohol level.  These symptoms may include:

Stage I: Tremulousness

  • Hand tremor
  • Anxiety
  • Agitation
  • Sleeping problems
  • Severe sweating
  • Poor appetite
  • Nausea
  • Rapid heart rate
  • High blood pressure
  • Hyper-reflexia
  • Hyperthermia

Stage II: Hallucinations

  • Occur within 12-48 hours of last drink
  • 3-10 % of withdrawal develop hallucinations
  • Duration is variable
  • Usually visual (pink elephants)
  • Occasionally auditory, tactile (formication), olfactory

Stage III: Seizures

  • Withdrawal seizures are more common in patients who have a history of multiple episodes of detoxification. Causes other than alcohol withdrawal should be considered if seizures are focal, if there is no definite history of recent abstinence from drinking, if seizures occur more than 48 hours after the patient’s last drink, or if the patient has a history of fever or trauma.
  • Occur within 6 to 48 hours of last drink
  • 3 to 15% of untreated patients develop seizures
  • It is grand-mal
  • Risk is increased by duration of alcohol abuse
  • 40% are single episodes
  • 30% of untreated patients go on to delirium tremens

Stage IV: Delirium tremens

Alcohol withdrawal delirium, or delirium tremens, is characterized by clouding of consciousness and delirium. Episodes of delirium tremens have a mortality rate of 1% to 5%. Risk factors for developing alcohol withdrawal delirium include concurrent acute medical illness, daily heavy alcohol use, history of delirium tremens or withdrawal seizures, older age, abnormal liver function, and more severe withdrawal symptoms on presentation.

What is Wernicke–Korsakoff syndrome (WKS)?

Wernicke’s encephalopathy is a degenerative brain disorder caused by the lack of thiamine (vitamin B1). It may result from alcohol abuse, dietary deficiencies, prolonged vomiting, eating disorders, or the effects of chemotherapy. B1 deficiency causes damage to the brain’s thalamus and hypothalamus.

Symptoms of Wernicke’s encephalopathy include:

  • mental confusion
  • vision problems
  • coma
  • hypothermia
  • low blood pressure
  • lack of muscle coordination (ataxia).

Korsakoff syndrome (also called Korsakoff’s amnesic syndrome) is a memory disorder that results from vitamin B1 deficiency and is associated with alcoholism. Korsakoff’s syndrome damages nerve cells and supporting cells in the brain and spinal cord, as well as the part of the brain involved with memory.

Symptoms of Korsakoff syndrome include:

  • amnesia
  • tremor
  • disorientation
  • vision problems
  • Coma

The main features of Korsakoff syndrome are problems in acquiring new information or establishing new memories, and in retrieving previous memories.

 

Treatment of WKS:

Treatment involves replacement of thiamine and providing proper nutrition and hydration. In some cases, drug therapy is also recommended. Stopping alcohol use may prevent further nerve and brain damage. In individuals with Wernicke’s encephalopathy, it is very important to start thiamine replacement before beginning nutritional replenishment.

What is the CIWA (Clinical Institute Withdrawal Assessment for Alcohol)?

  • CIWA: The revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale is a validated 10-item assessment tool that can be used to quantify the severity of alcohol withdrawal syndrome, and to monitor and medicate patients going through withdrawal
    1. CIWA-Ar scores of 8 points or fewer correspond to mild withdrawal,
    2. scores of 9 to 15 points correspond to moderate withdrawal, and
    3. Scores of greater than 15 points correspond to severe withdrawal symptoms and an increased risk of delirium tremens and seizures.
  • In using the CIWA-Ar, the clinical picture should be considered because medical and psychiatric conditions may mimic alcohol withdrawal symptoms.
  • Certain medications (e.g., beta blockers) may blunt the manifestation of these symptoms.

What laboratory work up is needed to be checked for?

  1. CBC, diff
  2. ALT, AST, GGT
  3. Urine drug screen
  4. Electrolyte levels
  5. Amylase
  6. Lipase
  7. Bilirubin, TG, Cholesterol
  8. LDH
  9. PT, PTT, INR
  10. Uric acid
  11. BUN, Creatinine
  12. Ca, Mg
  13. Phosphorus
  14. Protein
  15. Albumin

What medications are used for treatment of alcohol dependence?

Treatment of alcohol dependence is complex and requires a combination of medical, behavioural and psychosocial approaches.

Medications that are currently used for treatment of alcohol dependence can be classified as:

  1. Abuse prevention:
    1. Antabuse
  2. Seizure prevention and/or anxiety reduction:
    1. Benzodiazepines
    2. Gabapentin
    3. Phenobarbital
    4. Carbamazepin
    5. Propranolol or clonidine
  3. Craving reduction and relapse prevention:
    1. Naltrexone 50 to 150 mg once daily
    2. Campral 666 mg three times daily
  4. Supplements:
    1. Vitamine B1
    2. Magnesium

Treatments that are currently under question: 

There is mixed evidence about the efficacy and safety of balcofen in treatment of alcohol use disorder. This medication has been commonly used in France over the past couple of decades. A recent study analyzed data from French Health Insurance claims to assess the risk for hospitalization and death associated with initiating baclofen use. The study found that baclofen—compared with the other medications—was associated with increased risk of hospitalization (hazard ratio [HR], 1.1) and mortality (HR, 1.3). The study also found that as the dose increased the risk of hospitalization and mortality increased too. (Chaignot et all 2018)

What is the difference between Naltrexone and Campral?

Clinical studies have found acamprosate to be slightly more efficacious in promoting abstinence and naltrexone slightly more efficacious in reducing heavy drinking and craving. (Maisel et al, 2013)

What other treatments are available for treatment of alcohol dependence.

Behavioral approaches:

  • Cognitive behavioral therapy

Psychosocial approaches: 

  • Attending AA groups
  • Regular counseling
  • Family support

How can I estimate the risk of relapse?

The AWARE Questionnaire (Advance WArning of RElapse) is a questionnaire that is commonly used to predict the risk of relapse.

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