Alcohol-related disorder
Alcohol-related disorder: Excerpt from Professional Guide to Diseases (Eighth Edition)
The patient with alcohol-related disorder experiences a need for the daily intake of large amounts of alcohol for day-to-day functioning. A regular pattern of heavy drinking limited to weekends, with periods of sobriety between weekends, also suggests a pattern of abuse. People with these patterns of drinking usually show impaired social and occupational functioning.
Causes and incidence
Numerous biological, psychological, and sociocultural factors appear to be involved in alcohol addiction. An offspring of one parent with alcohol-related disorder is seven to eight times more likely to become an alcoholic than is a peer without such a parent. Biological factors may include genetic or biochemical abnormalities, nutritional deficiencies, endocrine imbalances, and allergic responses.
Psychological factors may include the urge to drink alcohol to reduce anxiety or symptoms of mental illness; the desire to avoid responsibility in familial, social, and work relationships; and the need to bolster self-esteem.
Sociocultural factors include the availability of alcoholic beverages, group or peer pressure, an excessively stressful lifestyle, and social attitudes that approve of frequent drinking.
More than 15% of American adults have a problem with alcohol use, and about 5% to 10% of male and 3% to 5% of female drinkers are alcohol dependent, accounting for about 12.5 million people. Alcohol-related disorder 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.
Signs and symptoms
Because the person with alcohol dependence may hide or deny his addiction, and may temporarily manage to maintain a functional life, assessing for alcohol-related disorder can be difficult. Note physical and psychosocial symptoms that suggest alcohol-related disorder. For example, 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, and interference with social and familial relationships and occupational responsibilities. Many minor complaints may be alcohol-related. The patient may report malaise, dyspepsia, mood swings or depression, and an increased incidence of infection. Observe the patient for poor personal hygiene and untreated injuries, such as cigarette burns, fractures, and bruises, that he can’t fully explain. Note any evidence of an unusually high tolerance of sedatives and opioids.
Although each person abusing alcohol may present in his own unique way, secretive or manipulative behavior may be a manifestation of the patient’s denial of the severity of his addiction. Suspect alcohol-related disorder if the patient uses inordinate amounts of aftershave or mouthwash. When confronted, the patient may deny or rationalize the problem. Alternatively, he may be guarded or hostile in his response and may even sign out of the hospital against medical advice. He also may project his anger or feelings of guilt or inadequacy onto others to avoid confronting his illness.
Chronic alcohol abuse brings with it an array of physical complications, including malnutrition, cirrhosis of the liver, peripheral neuropathy, brain damage, and cardiomyopathy. Assess for these complications in a patient with alcohol-related disorder. (See Complications of alcohol use.)
After abstinence or reduction of alcohol intake, signs and symptoms of withdrawal — which begin shortly after drinking has stopped and last for 5 to 7 days — may vary. The patient initially experiences anorexia, nausea, anxiety, fever, insomnia, diaphoresis, and tremor, progressing to severe tremulousness, agitation and, possibly, hallucinations and violent behavior. Major motor seizures (alcohol withdrawal seizures) can occur during withdrawal. Suspect alcohol-related disorder in any patient with unexplained seizures. (See Signs and symptoms of alcohol withdrawal.)
ELDER TIP Remember to consider the possibility of alcohol abuse when evaluating older patients. Research suggests that alcoholism affects 2% to 10% of adults older than age 60. More than half of all elderly hospital admissions are due to alcohol-related problems.
Diagnosis
For characteristic findings in patients with alcoholism, see Diagnosing substance dependence and related disorders, page 430.
Clinical findings may help support the diagnosis of alcohol-related disorder. For example, laboratory tests can confirm alcohol use and complications and document recent alcohol ingestion. A blood alcohol level ranging from 0.08% to 0.10% weight/volume (200 mg/dl) is accepted as the level of intoxication, depending on the state or country. The blood alcohol level in a physically dependent and tolerant drinker may exceed levels that would cause severe dysfunction or death in a nontolerant drinker. For example, a tolerant drinker might have a blood alcohol level of more than 0.5 mg (the usual lethal level) and still be alive, talking, and moving.
In severe hepatic disease, the blood urea nitrogen level is increased, and the serum glucose level is decreased. Further testing may reveal increased serum ammonia and amylase levels. Urine toxicology studies may help determine if the patient with alcohol withdrawal delirium or another acute complication abuses other drugs as well.
Liver function studies revealing increased levels of serum cholesterol, lactate dehydrogenase, alanine aminotransferase, aspartate aminotransferase, and creatine phosphokinase may point to liver damage, and elevated serum amylase and lipase levels point to acute pancreatitis. A hematologic workup can 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 (AA), 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.
Treatment of chronic alcohol abuse requires a varied approach that may include medications to deter alcohol use and treat effects of withdrawal; psychotherapy, consisting of behavior modification techniques, group therapy, and family therapy; and appropriate measures to relieve associated physical problems.
Aversion, or deterrent, therapy involves a daily oral dose of disulfiram to prevent compulsive drinking. This drug interferes with alcohol metabolism and allows toxic levels of acetaldehyde to accumulate in the patient’s blood, producing immediate and potentially fatal distress in the event he consumes alcohol up to 2 weeks after taking it. Disulfiram is contraindicated during pregnancy and in the patient with diabetes, heart disease, severe hepatic disease, or any disorder in which such a reaction could be especially dangerous. Another form of aversion therapy attempts to induce aversion by administering alcohol with an emetic.
The first drug approved by the U.S. Food and Drug Administration for the treatment of alcohol-related disorder since disulfiram is naltrexone, an opiate antagonist that effectively reduces the amount of intake, severity of craving, and relapse incidence. It’s believed to work by preventing the effects of increased endorphins produced as a product of increased alcohol intake.
For long-term success, the recovering individual must learn to fill the place alcohol once occupied in his life with something constructive. Therapy using disulfiram or naltrexone may only substitute one drug dependence for another, so it should be used prudently.
Benzodiazepine isn’t recommended during rehabilitation due to its addictive nature and the potential for reinforcing the substance abuse behavior.
ELDER TIP Because the older patient may be more sensitive to these drugs, withdrawal may take longer (weeks or months) and be more severe than in a younger adult.
Supportive counseling or individual, group, or family psychotherapy may help. Ongoing support groups are helpful. In AA, a self-help group with more than 1 million members worldwide, the alcoholic finds emotional support from others with similar problems. About 40% of AA’s members stay sober as long as 5 years, and 30% stay sober longer than 5 years.
Special considerations
❑ During acute intoxication or withdrawal, carefully monitor the patient’s mental status, heart rate, breath sounds, blood pressure, and temperature every 30 minutes to 6 hours.
❑ Assess the patient for signs of inadequate nutrition and dehydration. Institute seizure precautions and administer drugs prescribed to treat the signs and symptoms of withdrawal in chronic alcohol abuse.
❑ During withdrawal, orient the patient to reality because he may have hallucinations and may try to harm himself or others. 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. Limit sustained eye contact. Even if he’s verbally abusive, listen attentively and respond with empathy. Explain all procedures.
❑ Monitor the patient for signs of depression or impending suicide.
❑ In chronic alcohol-related disorder, help the patient accept his drinking problem and the necessity 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 of the effects of alcohol ingestion, which may last from 30 minutes to 3 hours or longer. The reaction includes 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. Even medicinal sources of alcohol, such as mouthwash, cough syrups, liquid vitamins, and cold remedies, must be avoided.
❑ Refer the patient to AA and offer to arrange a visit from an AA member. Stress the effectiveness of this organization.
❑ For the individual who has lost all contact with his family and friends and who has a long history of unemployment, trouble with the law, or other problems associated with alcohol abuse, rehabilitation may involve job training, sheltered workshops, halfway houses, and other supervised facilities.
❑ Refer the spouse of an alcoholic to Al-Anon and children of an alcoholic 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 tensions.
❑ Refer adult children of an alcoholic to the National Association for Children of Alcoholics.
Pictures
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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