A presentation on Alcohol Dependence and General Alcohol Physiology. Delivered in 2012.

1. Alcohol Dependence
2012
Alexandria Polles, MD

2. Alcohol Use
Spectrum
ABST
NON-
PROB
USE
AT-
RISK
USE
ABUSE DEP
Use
Consequences
Repetition
Loss of control, preoccupation, compulsivity, physical dependence
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3. General Alcohol Physiology
• 25% enters the bloodstream from the
stomach, 75% from the intestine
• 90% to 98% is removed in the liver, and
the remainder is excreted by the kidneys,
lungs, and skin.
• 70-kg man can metabolize 5 to 10 g
ethanol per hour (average drink contains
12 to 15 g ethanol)-alcohol
dehydrogenase 90%

4. Blood Alcohol Levels
Blood Ethanol
Level
Sporadic Drinkers Chronic
Tolerant
Drinkers
50-100 mg/dL or .5-1.0 g/dL Euphoria,
gregariousness,
incoordination
Minimal or no effect
100-200 Slurred speech, ataxia,
labile mood,
drowsiness, nausea
Sobriety or
incoordination
Euphoria
200-300 Lethargy,
combativeness Stupor,
incoherent speech,
vomiting
Mild emotional and
motor changes
300-400 Coma Drowsiness
>500 Death Lethargy, stupor,
comaadapted from Goldman: Cecil Textbook of Medicine, 21st ed., Copyright © 2000 W. B. Saunders Company

5. Diagnosis
• Structured Clinical Interview
of DSM-IV (SCID)
– Alcohol dependence
– Alcohol abuse
• Parallels the ICD-10

6. Alcohol Dependence
In the past 12 months 3+ of:
• Tolerance
• Withdrawal
• Increased use over time
• Loss of control
• Significant time spent obtaining, imbibing,
recovering
• Giving up important activities
• Continued use in spite of perceived adverse
consequences

7. Alcoholism Prevalence
• Abuse
– Men 13 %
– Women 6 %
• Dependence
– Men 20 %
– Women 8 %
Alcohol Medical Scholars Program
@ 2003

8. • Alcohol Use Disorder as currently proposed for DSM V
• A. A problematic pattern of alcohol use leading to clinically significant impairment or distress.
• B. Two (or more) of the following occurring within a 12-month period:
• 1. Alcohol is often taken in larger amounts or over a longer period than was intended
• 2. There is a persistent desire or unsuccessful effort to cut down or control alcohol use
• 3. A great deal of time is spent in activities necessary to obtain alcohol, use the substance, or recover from its effects
• 4. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor
work performance related to alcohol use; substance-related absences, suspensions, or expulsions from school; neglect of children or
household)
• 5. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects
of the substance
• 6. Important social, occupational, or recreational activities are given up or reduced because of alcohol use
• 7. Recurrent alcohol use in situations in which it is physically hazardous
• 8. 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 the substance
• 9. Tolerance, as defined by either or both of the following:
• a. A need for markedly increased amounts of alcohol to achieve intoxication or desired effect
• b. Markedly diminished effect with continued use of the same amount of the substance
• 10. Withdrawal, as manifested by either of the following:
• a. The characteristic withdrawal syndrome for alcohol (refer to Criteria A and B of the criteria set for Withdrawal)
• b. The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
• 11. Craving or a strong desire or urge to use alcohol
• Specify the following:
• Early Remission. This specifier is used if, for at least 3 months, but for less than 12 months, the individual does not meet any of the
criteria 1-10 for a Substance Use Disorder (i.e. none of the criteria except for Criterion 11, “Craving or a strong desire or urge to use a
specific substance”).
• Sustained Remission. This specifier is used if none of the criteria 1-10 for a Substance Use Disorder have been met at any time during a
period of 12 months or longer (i.e. none of the criteria met except for Criterion 11, “Craving or a strong desire or urge to use a specific
substance”)
• In a Controlled Environment. This additional specifier is used if the individual is in an environment where access to alcohol and
controlled substances is restricted, and no criteria for a Substance Use Disorder have been met. Examples of these environments are
closely supervised and substance-free jails, therapeutic communities, and locked hospital units.
8

9. Clinical Course
Early milestones similar to general population
• First drink ~age 13
• First intoxication ~age 16
• First problem ~age 21
40% of all drinkers have some minor problem
at some time, those with alcoholism
can’t/don’t stop because of these problems

10. Clinical Course
• Dependence ~age 28
• Variable course
• Frequent periods of abstinence of varying
lengths
• Spontaneous remission does occur but
very risky to assume this

11. Medical Morbidity
• Dependence cuts 15 years off the lifespan
• Deaths from
– Heart disease
– Cancer
– Accidents/Trauma
– Suicide

12. Psychiatric Symptoms in
Alcoholism
• Almost all have a sleep disturbance
• Many experience
– Depression
– Anxiety
– Psychosis (less likely)
– Irritability
• Most symptoms resolve with abstinence
but must be monitored

13. Addiction
• Loss of control
• Compulsivity
• Continuation despite
consequences
– Legal
– Financial
– Medical
– Social

15. Chemical Dependency: A Disease
• To be a disease, a condition must qualify 4 ways:
– A specific cause
– A specific group of signs and symptoms
– A predictable clinical course
– A predictable outcome
• Characteristics of Chemical Dependency
– Primary
– Progressive
– Chronic
– Fatal

16. The Alcoholic Progression
Dr. E. Morton Jellinek – “Disease
Concept” of Alcoholism

17. CAGE QUESTIONNAIRE
(acronym for 4 questions)
• 1. Have you ever felt you needed to Cut down on your
drinking?
• 2. Have people Annoyed you by criticizing your
drinking?
• 3. Have you ever felt Guilty about drinking?
• 4. Have you ever felt you needed an Eye-opener to
steady your nerves or to get rid of a hangover?
– 2 yes indicate possibility of alcoholism should be further
investigated
– Validated screening method with scores of 2 or more having a
sensitivity of 93% and specificity of 76%

18. AUDIT-C
1. How often did you have a drink containing alcohol in the
past year?
Never=0;</=Monthly=1;2-4 x a month=2;2-3 x a week=3;>/=4 x a week = 4
2. How many drinks did you have on a typical day when
you were drinking in the past year?
1-2=0;3-4=1;5-6=2;7-9=3;>/=10=4
3. How often did you have 6 or more drinks on one
occasion during the past year?
Never=0;Less than monthly=1;Monthly=2;Weekly=3;Daily or almost daily=4
Score of 4 in men or 3 in women is positive.

20. Structured Assessment Forms used in
Symptom-Triggered Therapy
for Medically Managed Detoxification
• Clinical Institute Withdrawal Assessment
for Alcohol Scale (CIWA-A)
• Clinical Institute Withdrawal Assessment
for Alcohol, revised (CIWA-Ar)
• CIWA-A, modified (Foy, et.al)

21. Symptoms of Alcohol Withdrawal
Hours after
last drink
Symptoms of
Withdrawal
Peak Duration
6-12 hrs Tremors, N/V,
anxiety, agitation
tachycardia, HTN,
insomnia, fever
24-36
hrs
48hrs
6-48 hrs Seizures
48-72 hrs Hallucinations
3-5 days Delirium tremens 2-5
days

22. Alcohol Withdrawal Seizures
• Typically generalized seizures (tonic-clonic)
• Usually 24-48 hours after last drink but may be
within 8 hours or after several days
• BAL does not have to be zero
• Rarely progresses to status epilepticus
• Increased risk if prior seizure or detoxing off
sedative hypnotic or barbiturate as well or if on
other psychotropics that lower seizure threshold
(eg., buproprion, SSRIs, neuroleptics)

23. Treatment of Alcoholism
• Traditional Inpatient/Outpatient
• 12 step: AA(oldest, common)
• Medication
• Usually a combination of all 3

24. Treatment of Alcoholism
• Traditional Inpatient/Outpatient
• Patient Placement Criteria
• 12 step: AA(oldest, common),
Specialty groups
• Medication
• Usually a combination of all 3

25. Medications for
Alcohol Dependence
• Approved oral medications
-Naltrexone
-Acamprosate
-Disulfiram
• Approved injectable medication
-Extended-release injectable naltrexone
Off label/non approved
Topiramate

26. Alcohol Use Disorders
Treatment
• Typically a cognitive-behavioral and
abstinence based model
• Motivational Interviewing
• Stages of Change
• Should incorporate “12 step” concepts or
recommendations

27. General Predictors of the
Outcome of Treatment
• Severity of addiction or withdrawal
• Psychiatric Co-morbidity
• Substance Related
Problems/Consequences
• Multi-Substance Abuse
• Length of Treatment
• Genetic (Cloniger’s Type I and Type II)
• Socio-Economic
Psychiatric Clinics N Am 26 (2003) 381–409

28. Summary
• There are useful alcohol screening and
guidelines – but they have to be used.
• Medications appropriate and helpful for
some
• There is no substitute for traditional
therapy and 12 step interventions
• Use of multiple interventions is likely to be
of greater benefit than any single
approach.