The lifetime risk for an alcohol use disorder in most Western countries is about 10–15% for men and 5–8% for women. Rates are similar in the United States, Canada, Germany, Australia, and the United Kingdom, tend to be lower in most Mediterranean countries, such as Italy, Greece, and Israel, and may be higher in Ireland, France, and Scandinavia. An even higher lifetime prevalence has been reported for most native cultures, including American Indians, Eskimos, Maori groups, and aboriginal tribes of Australia. These differences reflect both cultural and genetic influences, as described below. In Western countries, the typical alcoholic is more often a blue- or white-collar worker or homemaker. The lifetime risk for alcoholism among physicians is similar to that of the general population.
Although the age of the first drink (~15 years) is similar in most alcoholics and nonalcoholics, a slightly earlier onset of regular drinking and drunkenness, especially in the context of conduct problems, is associated with a higher risk for later alcohol use disorders. By the mid-twenties, most nonalcoholic men and women moderate their drinking (perhaps learning from problems), whereas alcoholics are likely to escalate their patterns of drinking despite difficulties. The first major life problem from alcohol often appears in the late teens to early twenties, and a pattern of multiple alcohol difficulties by the midtwenties. Once established, the course of alcoholism is likely to include exacerbations and remissions, with little difficulty in temporarily stopping or controlling alcohol use when problems develop, but without help, desistance usually gives way to escalations in alcohol intake and subsequent problems. Following treatment, between half and two-thirds of alcoholics maintain abstinence for years, and often permanently. Even without formal treatment or self-help groups, there is at least a 20% chance of spontaneous remission with long-term abstinence. However, should the alcoholic continue to drink heavily, the life span is shortened by ~10 years on average, with the leading causes of death being heart disease, cancer, accidents, and suicide.
TREATMENT: Alcohol-Related Conditions ACUTE INTOXICATION
The first priority in treating severe intoxication is to assess vital signs and manage respiratory depression, cardiac arrhythmias, or blood pressure instability, if present. The possibility of intoxication with other drugs should be considered by obtaining toxicology screens for other central nervous system (CNS) depressants such as benzodiazepines and for opioids. Aggressive behavior should be handled by offering reassurance but also by considering a possible show of force with an intervention team. If the aggressive behavior continues, relatively low doses of a short-acting benzodiazepine such as lorazepam (e.g., 1–2 mg PO or IV) may be used and can be repeated as needed, but care must be taken not to destabilize vital signs or worsen confusion. An alternative approach is to use an antipsychotic medication (e.g., 0.5–5 mg of haloperidol PO or IM every 4–8 h as needed, or olanzapine 2.5–10 mg IM repeated at 2 and 6 h, if needed). INTERVENTION
There are two main elements to intervention in a person with alcoholism: motivational interviewing and brief interventions. During motivational interviewing, the clinician helps the patient to think through the assets (e.g., comfort in social situations) and liabilities (e.g., health- and interpersonal-related problems) of the current pattern of drinking. The patient’s responses are key, and the clinician should listen empathetically, helping to weigh options and encouraging the patient to take responsibility for needed changes. Patients should be reminded that only they can decide to avoid the consequences that will occur without changes in drinking. The process of brief intervention has been summarized by the acronym FRAMES: Feedback to the patient; Responsibility to be taken by the patient; Advice, rather than orders, on what needs to be done; Menus of options that might be considered; Empathy for understanding the patient’s thoughts and feelings; and Self-efficacy, i.e., offering support for the capacity of the patient to make changes.
Once the patient begins to consider change, the emphasis shifts to brief interventions designed to help them understand more about potential actions. Discussions focus on consequences of high alcohol consumption, suggested approaches to stopping drinking, and help in recognizing and avoiding situations likely to lead to heavy drinking. Both motivational interviewing and brief interventions can be carried out in 15-min sessions, but because patients do not always change behavior immediately, multiple meetings are often required to explain the problem, discuss optimal treatments, and explain the benefits of abstinence. ALCOHOL WITHDRAWAL
If the patient agrees to stop drinking, sudden decreases in alcohol intake can produce withdrawal symptoms, many of which are the opposite of those produced by intoxication. Features include tremor of the hands (shakes); agitation and anxiety; autonomic nervous system overactivity including an increase in pulse, respiratory rate, sweating, and body temperature; and insomnia. These symptoms usually begin within 5–10 h of decreasing ethanol intake, peak on day 2 or 3, and improve by day 4 or 5, although mild levels of these problems may persist for 4–6 months as a protracted abstinence syndrome.
About 2% of alcoholics experience a withdrawal seizure, with the risk increasing in the context of concomitant medical problems, misuse of additional drugs, and higher alcohol quantities. The same risk factors also contribute to a similar rate of delirium tremens (DTs), where the withdrawal includes delirium (mental confusion, agitation, and fluctuating levels of consciousness) associated with a tremor and autonomic overactivity (e.g., marked increases in pulse, blood pressure, and respirations). The risks for seizures and DTs can be diminished by identifying and treating any underlying medical conditions early in the course of withdrawal.
Thus, the first step is a thorough physical examination in all alcoholics considering abstinence, including a search for evidence of liver failure, gastrointestinal bleeding, cardiac arrhythmia, infection, and glucose or electrolyte imbalances. It is also important to offer adequate nutrition and oral multiple B vitamins, including 50–100 mg of thiamine daily for a week or more. Because most alcoholics who enter withdrawal are either normally hydrated or mildly overhydrated, IV fluids should be avoided unless there is a relevant medical problem or significant recent bleeding, vomiting, or diarrhea.
The next step is to recognize that because withdrawal symptoms reflect the rapid removal of a CNS depressant, alcohol, the symptoms can be controlled by administering any depressant in doses that decrease symptoms (e.g., a rapid pulse and tremor) and then tapering the dose over 3–5 days. Although most depressants are effective, benzodiazepines (Chap. 61) have the highest margin of safety and lowest cost and are, therefore, the preferred class of drugs. Short-half-life benzodiazepines can be considered for patients with serious liver impairment or evidence of significant brain damage, but they must be given every 4 h to avoid abrupt blood-level fluctuations that may increase the risk for seizures. Therefore, most clinicians use drugs with longer half-lives (e.g., chlordiazepoxide), adjusting the dose if signs of withdrawal escalate, and withholding the drug if the patient is sleeping or has orthostatic hypotension. The average patient requires 25–50 mg of chlordiazepoxide or 10 mg of diazepam given PO every 4–6 h on the first day, with doses then decreased to zero over the next 5 days. Although alcohol withdrawal can be treated in a hospital, patients in good physical condition who demonstrate mild signs of withdrawal despite low blood alcohol concentrations and who have no prior history of DTs or withdrawal seizures can be considered for outpatient detoxification. For the next 4 or 5 days, these patients should return daily for evaluation of vital signs and can be hospitalized if signs and symptoms of withdrawal escalate.
Treatment of patient with DTs can be challenging, and the condition is likely to run a course of 3–5 days regardless of the therapy used. The focus of care is to identify and correct medical problems and to control behavior and prevent injuries. Many clinicians recommend the use of high doses of a benzodiazepine (as much as 800 mg/d of chlordiazepoxide has been reported), a treatment that will decrease agitation and raise the seizure threshold but probably does little to improve the confusion. Other clinicians recommend the use of antipsychotic medications, such as haloperidol or olanzapine as discussed above, although these drugs have not been directly evaluated for DTs. Antipsychotics are less likely to exacerbate confusion but may increase the risk of seizures; they have no place in the treatment of mild withdrawal symptoms.
Generalized withdrawal seizures rarely require more than giving an adequate dose of benzodiazepines. There is little evidence that anticonvulsants such as phenytoin or gabapentin are more effective in drug-withdrawal seizures, and the risk of seizures has usually passed by the time effective drug levels are reached. The rare patient with status epilepticus must be treated aggressively (Chap. 31). REHABILITATION OF ALCOHOLICS An overview
After completing alcoholic rehabilitation, ≥60% of alcoholics, especially middle-class patients, maintain abstinence for at least a year, and many achieve lifetime sobriety. The core of treatment uses cognitive-behavioral approaches to help patients recognize the need to change, while working with them to alter their behaviors to enhance compliance. A key step is to optimize motivation toward abstinence through education about alcoholism and instructions to family members to stop protecting the patient from problems caused by alcohol. After years of heavy drinking, many patients also need counseling, some require vocational or avocational help to structure their days, and all should try self-help groups such as Alcoholics Anonymous (AA) to help them develop a sober peer group and learn how to deal with life’s stresses while sober. A third component, relapse prevention, helps the patient identify situations in which a return to drinking is likely, formulate ways of managing these risks, and develop coping strategies that increase the chances of a return to abstinence if a slip occurs.
Although many can be treated as outpatients, more intense interventions are more effective, and some alcoholics do not respond to AA or outpatient groups. Whatever the setting, subsequent contact with outpatient treatment staff should be maintained for at least 6 months and preferably a year after abstinence. Counseling focuses on areas of improved functioning in the absence of alcohol (i.e., why it is a good idea to continue abstinence) and helping the patient to manage free time without alcohol, develop a nondrinking peer group, and handle stresses.
The physician serves an important role in identifying the alcoholic, diagnosing and treating associated medical and psychiatric syndromes, overseeing detoxification, referring the patient to rehabilitation programs, providing counseling, and, if appropriate, selecting which (if any) medication might be needed. For insomnia, patients should be reassured that troubled sleep is normal after alcohol withdrawal and will improve over subsequent weeks. They should be taught the elements of “sleep hygiene” including maintaining consistent schedules for bedtime and awakening. Sleep medications have the danger of being misused and of rebound insomnia when stopped. Sedating antidepressants (e.g., trazodone) should not be used because they interfere with cognitive functioning the next morning and disturb the normal sleep architecture, but occasional use of over-the-counter sleeping medications (sedating antihistamines) can be considered. Anxiety can be addressed by increasing the patient’s insight into the temporary nature of the symptoms and helping the patient to develop strategies to achieve relaxation by using forms of cognitive therapy. Medications for rehabilitation
Several medications have modest benefits when used for the first 6 months of recovery. The opioid antagonist, naltrexone, 50–150 mg/d orally, may shorten subsequent relapses, whether used in the oral form or as a once-per-month 380-mg injection, especially in individuals with the G allele of the AII8G polymorphism of the μ opioid receptor. By blocking opioid receptors, naltrexone decreases activity in the dopamine-rich ventral tegmental reward system and decreases the feeling of pleasure if alcohol is imbibed. A second medication, acamprosate (Campral) at ~2 g/d divided into three oral doses, has similar modest effects; acamprosate inhibits NMDA receptors, decreasing mild symptoms of protracted withdrawal. Several trials of combined naltrexone and acamprosate have reported that the combination may be superior to either drug alone, although not all studies agree.
It is more difficult to establish the asset-to-liability ratio of a third drug, disulfiram, an ALDH inhibitor, used at doses of 250 mg/d. This drug produces vomiting and autonomic nervous system instability in the presence of alcohol as a result of rapidly rising blood levels of acetaldehyde. This reaction can be dangerous, especially for patients with heart disease, stroke, diabetes mellitus, or hypertension. The drug itself carries potential risks of depression, psychotic symptoms, peripheral neuropathy, and liver damage. Disulfiram is best given under supervision by someone (such as a spouse), especially during high-risk drinking situations (such as the Christmas holiday). Other drugs under investigation include another opioid antagonist nalmefene, the nicotinic receptor agonist varenicline, the serotonin antagonist ondansetron, the α-adrenergic agonist prazosin, the GABAB receptor agonist baclofen, the anticonvulsant topiramate, and cannabinol receptor antagonists. At present, there are insufficient data to determine the asset-to-liability ratio for these medications in treating alcoholism and, therefore, no data to offer solid support for their use in routine clinical settings.
As described above, rates of alcohol use disorders differ across sex, age, ethnicity, and country. There are also differences across countries regarding the definition of a standard drink (e.g., 10–12 g of ethanol in the United States and 8 g in the United Kingdom) and the definition of being legally drunk. The preferred alcoholic beverage also varies across groups, even within countries. That said, regardless of sex, ethnicity, or country, the actual drug in the drink is still ethanol, and the risks for problems, course of alcohol use disorders, and approaches to treatment are similar across the world.