Alcoholism
Alcoholism: Excerpt from Handbook of Diseases
A chronic disorder, alcoholism is usually described as an uncontrolled intake of alcoholic beverages that interferes with physical and mental health, social and family relationships, and occupational responsibilities. Alcoholism cuts across all social and economic groups, involves both sexes, and occurs at all stages of the life cycle, beginning as early as elementary school age. About 20% of patients, even in affluent areas, have alcoholism. Lifetime risk for dependence is 10% to 15% for men and 5% for women.
Causes
Numerous biological, psychological, and sociocultural factors appear to be involved in alcohol addiction. An offspring of one alcoholic parent is seven to eight times more likely to become an alcoholic than is a peer without an alcoholic parent. Biological factors include genetic and biochemical abnormalities, nutritional deficiencies, endocrine imbalances, and allergic responses.
Psychological factors include the urge to drink alcohol to reduce anxiety or symptoms of mental illness; the desire to avoid responsibility in family, social, and work relationships; and the need to bolster self-esteem.
Sociocultural factors include the availability of alcoholic beverages, peer pressure, an excessively stressful lifestyle, and social attitudes that approve of frequent drinking.
Signs and symptoms
Because people with alcohol dependence may hide or deny their addiction and may temporarily manage to maintain a functional life, assessing a patient for alcoholism can be difficult. However, there are various physical and psychosocial symptoms that can facilitate assessment.
The patient’s history may suggest a need for daily or episodic alcohol use to maintain adequate functioning, an inability to discontinue or reduce alcohol intake, episodes of anesthesia or amnesia (blackouts) during intoxication, episodes of violence during intoxication, or interference with social and familial relationships and occupational responsibilities.
Many minor complaints that the patient may have may also be alcohol related. He may mention malaise, dyspepsia, mood swings, depression, or more infections. Note any evidence of an unusually high tolerance for sedatives and narcotics.
Secretive behavior is another indication. When confronted, the patient may deny or rationalize his problem with alcohol. Alternatively, he may be guarded or hostile in his response. He also may project his anger or feelings of guilt or inadequacy onto others to avoid confronting his illness.
With chronic alcohol abuse, the patient may experience malnutrition, cirrhosis of the liver, peripheral neuropathy, brain damage, or cardiomyopathy.
After abstaining from alcohol or significantly reducing his intake, the patient may experience signs and symptoms of withdrawal, and they may last for 5 to 7 days. The patient initially experiences anorexia, nausea, anxiety, fever, insomnia, diaphoresis, and tremor, progressing to severe tremulousness, agitation and, possibly, hallucinations and violent behavior. Major tonic-clonic seizures (known as rum fits) can occur during withdrawal. Suspect alcoholism in any patient with unexplained seizures.
Diagnosis
For characteristic findings in patients with alcoholism, see Diagnosing substance dependence and related disorders, page 286.
Laboratory values may help support the diagnosis of alcoholism — for example, they can confirm alcohol use and complications and indicate recent alcohol ingestion:
Blood alcohol level of 0.10% weight/volume (200 mg/dl) is accepted as the level of intoxication.
Blood urea nitrogen level rises in severe hepatic disease.
Blood glucose level is decreased.
Serum ammonia and amylase levels are increased.
Urine toxicology studies may help detect other types of drug abuse in patients with alcohol withdrawal delirium or another acute complication.
Liver function studies reveal increased levels of serum cholesterol, lactate dehydrogenase, alanine aminotransferase, aspartate aminotransferase, and creatine kinase (which indicate liver damage) and elevated serum amylase and lipase levels (which indicate acute pancreatitis).
Blood studies may identify anemia, thrombocytopenia, increased prothrombin time, and increased partial thromboplastin time.
Treatment
Total abstinence from alcohol is the only effective treatment. Supportive programs that offer detoxification, rehabilitation, and aftercare, including continued involvement in Alcoholics Anonymous, may produce good long-term results.
Acute intoxication is treated symptomatically by supporting respiration, preventing aspiration of vomitus, replacing fluids, administering I.V. glucose to prevent hypoglycemia, correcting hypothermia or acidosis, and initiating emergency treatment for trauma, infection, or GI bleeding. Acute withdrawal is also treated with oral multiple B vitamins, including thiamine. Administer fluids as needed, but avoid overhydrating the patient.
CLINICAL TIP: The possibility of intoxication with other drugs should be considered and a blood or urine sample sent for toxicology as appropriate.
Treatment of chronic alcoholism involves counseling, education, and cognitive techniques; psychotherapy (consisting of behavior modification techniques, group therapy, and family therapy); and appropriate measures to relieve associated physical problems.
Aversion, or deterrent, therapy may involve a daily oral dose of disulfiram to prevent compulsive drinking. (See Avoiding the risks of disulfiram therapy.)
UNDER STUDY: The opioid-antagonist drug naltrexone has been shown to reduce the ability to return to drinking and shorten periods of relapse. Longer-term trials are needed.
Tranquilizers, particularly the benzodiazepines, are used to decrease withdrawal symptoms of the central nervous system and are administered routinely to decrease risk of seizures. These drugs are administered and decreased over 3 to 5 days. Status epilepticus should be treated aggressively; initial treatment with lorazepam I.V. is effective.
Supportive counseling or individual, group, or family psychotherapy may help. Ongoing support groups are also helpful.
Special considerations
During acute intoxication or withdrawal, carefully monitor the patient’s mental status, heart rate, breath sounds, and blood pressure every 15 minutes until stable, then every hour for 6 hours. Also, closely monitor the patient’s temperature until stable.
Examine the patient for signs of inadequate nutrition and dehydration. Institute seizure precautions, and administer drugs prescribed to treat the signs and symptoms of withdrawal.
Maintain a calm environment, minimizing noise and shadows to reduce the incidence of delusions and hallucinations. Avoid restraining the patient unless necessary to protect him or others.
Approach the patient in a nonthreatening way, listen attentively, and respond with empathy. Explain all procedures.
Monitor the patient for signs of depression or an impending suicide attempt.
If the patient suffers from chronic alcoholism, help him to accept his drinking problem and to realize the need for abstinence. Confront him about his behavior, urging him to examine his actions more realistically.
If the patient is taking disulfiram (or has taken it within the past 2 weeks), warn him that ingesting alcohol can cause a disulfiram reaction, which may last from 30 minutes to 3 hours or longer. Signs and symptoms include nausea, vomiting, facial flushing, headache, shortness of breath, red eyes, blurred vision, sweating, tachycardia, hypotension, and fainting. Emphasize that even a small amount of alcohol will induce this adverse reaction and that the longer he takes the drug, the greater his sensitivity to alcohol will be. Because of this, he must avoid even medicinal sources of alcohol, such as mouthwash, cough syrups, liquid vitamins, and cold remedies.
For some individuals, rehabilitation may involve job training, sheltered workshops, halfway houses, and other supervised facilities.
Refer spouses of alcoholics to Al-Anon and children of alcoholics to Alateen. By participating in these self-help groups, family members learn to relinquish responsibility for the individual’s drinking. Point out that family involvement in rehabilitation can reduce family tension.
Refer adult children of alcoholics to the National Association for Children of Alcoholics. Pictures
Book Source Details
- Book Title: Handbook of Diseases
- Author(s): Springhouse
- Year of Publication: 2003
- Copyright Details: Handbook of Diseases, Copyright © 2003 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Handbook of Diseases
Authors: Springhouse
Publisher: Lippincott Williams & Wilkins
Copyright: 2003
ISBN: 1-58255-266-5
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