Excessive Alcohol use is the third leading cause of preventable death in the United States. Liability to alcohol abuse and dependence, especially early-onset abuse, runs in families, but the mechanism of inheritance is not understood. Alcohol is a central nervous system (CNS) depressant with cross-tolerance to benzodiazepines, barbiturates, and some other sedative.
Acute alcohol intoxication at moderate doses causes disinhibition and incoordination. Even at socially acceptable doses, it impairs driving and is implicated in approximately half of all highway accidents and deaths. Alcohol is linked to a similar proportion of sexual assaults.
Patients with most major psychiatric illnesses have increased rates of alcohol abuse. Alcohol interacts with psychiatric illnesses and treatments. Many patients use alcohol to treat mood disorders, anxiety, or insomnia, but it is not a safe or effective treatment for any medical disorder.
Alcohol has direct toxic effects on multiple tissues, including the central nervous system, liver, the pancreas, and the heart. Patients may present with acute or chronic hepatitis, cirrhosis, esophageal varices, cardiomyopathy, and dementia. Acute withdrawal syndromes occur occasionally, leading to delirium tremens, Wernicke encephalopathy, and Korsakoff psychosis.
Criteria for the Diagnosis of Alcohol Use Disorder
A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:
Alcohol is often taken in larger amounts or over a longer period than was intended.
There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.
A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.
Craving, or a strong desire or urge to use alcohol.
Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home.
Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.
Important social, occupational, or recreational activities are given up or reduced because of alcohol use.
Recurrent alcohol use in situations in which it is physically hazardous.
Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.
Tolerance, as defined by either of the following: (a). A need for markedly increased amounts of alcohol to achieve intoxication or desired effect. (b). A markedly diminished effect with continued use of the same amount of alcohol.
Withdrawal, as manifested by either of the following: (a). The characteristic withdrawal syndrome for alcohol. (b). Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.
DIAGNOSIS
There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.
A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.
Craving, or a strong desire or urge to use alcohol.
Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home.
Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.
Important social, occupational, or recreational activities are given up or reduced because of alcohol use.
Recurrent alcohol use in situations in which it is physically hazardous.
Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.
Tolerance, as defined by either of the following: (a). A need for markedly increased amounts of alcohol to achieve intoxication or desired effect. (b). A markedly diminished effect with continued use of the same amount of alcohol.
Withdrawal, as manifested by either of the following: (a). The characteristic withdrawal syndrome for alcohol. (b). Alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.
DIAGNOSIS
To avoid missing the diagnosis of alcohol abuse or dependence, physicians must maintain a high index of suspicion directed at eliciting classic historic signs of impending alcohol abuse.
When diagnostic uncertainty persists, interviewing family or friends is often decisive; typically, they present a more accurate picture of the patient’s drinking habits.
TREATMENT
Withdrawal from alcohol and other cross-tolerant sedative hypnotics (barbiturates, benzodiazepines, methaqualone, etc.) is potentially hazardous. This can lead to agitated delirium and seizures. In contrast, most other pharmacologic withdrawals are characterized by dysphoria but are not medically dangerous; nevertheless, withdrawal from cocaine and amphetamines can lead to a profound depression.
Pharmacologic treatments for addiction are improving but are still adjunctive to psychotherapeutic and behavioral interventions. Long-term replacement of illicit opiates with methadone or buprenorphine is effective, as is the temporary use of nicotine administered by patch, gum, or inhalation to help smokers quit. The use of bupropion modestly increases the success rate of quitting cigarettes. Varenicline, a nicotine receptor partial agonist, works even better, but possibly at the cost of precipitating mood disturbances.
Disulfiram (Antabuse) is the oldest specific medicine to be prescribed to prevent use of alcohol. Unexpectedly, disulfiram also has been found to have some utility for therapy of cocaine abuse. By inhibiting a critical hepatic enzyme in the metabolic degradation of alcohol, disulfiram induces an unpleasant and potentially dangerous reaction to this therapy, whenever the reforming addict returns to alcohol ingestion. Disulfiram works best in highly motivated but intermittently impulsive binge drinkers. However, this therapeutic approach is not only potentially hazardous but totally dependent on patient motivation. It is easy for an alcoholic to simply choose to stop using the medicine.
Two other medications are approved for the treatment of alcoholism: Naltrexone is an opiate antagonist that also reduces alcohol intake, presumably by diminishing the rewarding effects of alcohol. Acamprosate is thought to subtly diminish protracted withdrawal systems by modulating glutamatergic activity.
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