Alcoholism

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.

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.

Risk Factors

Genetic

Preexisting psychiatric disorder

Early onset of alcohol consumption

Stress

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

Differential Diagnosis

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

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.

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

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

Imaging

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

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

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)

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

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.

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.

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.

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

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.

Patient Monitoring

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

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.

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

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.

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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