IntroductionAlcohol (beverage ethanol) distributes throughout the body,affecting almost all systems and altering nearly everyneurochemical process in the brain. This drug is likely toexacerbate most medical conditions, affect almost anymedication metabolized in the liver, and temporarily mimicmany medical (e.g., diabetes) and psychiatric (e.g.,depression) conditions. Because 80% of people in Westerncountries have consumed alcohol, and two-thirds have beendrunk in the prior year, the lifetime risk for serious, repetitivealcohol problems is almost 20% for men and 10% for women,regardless of a persons education or income.
Pharmacology and Nutritional Impact of EthanolBlood levels of ethanol are expressed as milligramsor grams of ethanol per deciliter (e.g., 100 mg/dL =0.10 g/dL), with values of 0.02 g/dL resulting fromthe ingestion of one typical drink. In round figures,340 mL (12 oz) of beer, 115 mL (4 oz) ofnonfortified wine, and 43 mL (1.5 oz) (a shot) of 80-proof beverage such as whisky, gin, or vodka eachcontain 10–15 g of ethanol and represent a standarddrink;0.5 L (1 pint) of 80-proof beverage contains160 g (about 16 standard drinks), and 750 mL ofwine contains 60 g of ethanol.
Definitions and EpidemiologyAlcohol dependence is defined in DSM-IV asrepeated alcohol-related difficulties in at least threeof seven life areas that cluster together at about thesame time (e.g., over the same 12-month period).Two of these seven items, tolerance and withdrawal,may have special importance as they are associatedwith a more severe clinical course. Dependencepredicts a course of recurrent problems with the useof alcohol and the consequent shortening of the lifespan by a decade.
Myths Most alcoholics are skid-row bums Mixing drinks makes you drunk faster Black coffee or cold showers can sober you up Beer drinkers are less likely to become alcoholics Sex is better after a few drinks
Stages of Alcoholism Introductory Stage Early, Forewarning Stage Middle Crucial Stage Final Chronic Stage
Conditions of Alcoholism Consumption of large quantities over an extended period. Psychological dependence Physical addiction Alcohol-related problems
Effects of alcohol Short-term (individual) Long-Term (individual) Social Effects Crime & Alcohol
Social Profile Gender & Age Race & Ethnicity Religious Affiliation Socio-economic status Region
Theories of Alcoholism Genetic Theories: “A” gene Blushing response The Alcoholic Personality Sociological Theories – degree of fit
Controlling alcohol use & abuse Legal measures Prohibition Age limits Therapeutic approaches AA Rational recovery
Acute IntoxicationAggressive behavior should be handled by offeringreassurance but also by considering the possibility of a showof force with an intervention team. If the aggressive behaviorcontinues, relatively low doses of a short-actingbenzodiazepine such as lorazepam (e.g., 1–2 mg PO or IV)may be used and can be repeated as needed, but care must betaken not to destabilize vital signs or worsen confusion. Analternative approach is to use an antipsychotic medication(e.g., 0.5–5 mg of haloperidol PO or IM every 4–8 h asneeded, or olanzapine 2.5–10 mg IM repeated at 2 and 6 h, ifneeded).
InterventionThere are two main elements to intervention in a person withalcoholism: motivational interviewing and brief interventions.During motivational interviewing, the clinician helps thepatient to think through the assets (e.g., comfort in socialsituations) and liabilities (e.g., health and interpersonal relatedproblems) of the current pattern of drinking.Once the patient begins to consider change, the emphasisshifts to brief interventions designed to help the patientunderstand more about potential action. Discussions focus onconsequences of high alcohol consumption, suggestedapproaches to stopping drinking, and help in recognizing andavoiding situations likely to lead to heavy drinking.
Alcohol WithdrawalFeatures include tremor of the hands (shakes);agitation and anxiety; autonomic nervous systemoveractivity including an increase in pulse,respiratory rate, and body temperature; andinsomnia. These symptoms usually begin within 5–10 h of decreasing ethanol intake, peak on day 2 or3, and improve by day 4 or 5, although mild levels ofthese problems may persist for 4–6 months as aprotracted abstinence syndrome.
Alcohol WithdrawalIt is also important to offer adequate nutrition and oralmultiple B vitamins, including 50–100 mg of thiamine dailyfor a week or more. Because most alcoholics who enterwithdrawal are either normally hydrated or mildlyoverhydrated, IV fluids should be avoided unless there is arelevant medical problem or significant recent bleeding,vomiting, or diarrhea.The average patient requires doses of 25–50 mg ofchlordiazepoxide or 10 mg of diazepam given PO every 4–6 hon the first day, with doses then decreased to zero over thenext 5 days.
Medications for RehabilitationSeveral medications have modest benefitswhen used for the first 6 months of recovery.The opioid-antagonist, naltrexone, 50–150mg/d orally, appears to shorten subsequentrelapses, whether used in the oral form or as aonce-per-month 380-mg injection, especiallyin individuals with the G allele of the AII8Gpolymorphism of the opioid receptor.