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Alcoholism

  • Author: Warren Thompson, MD, FACP; Chief Editor: Iqbal Ahmed, MBBS, FRCPsych(UK)  more...
 
Updated: Apr 07, 2016
 

Practice Essentials

Alcohol use is the fourth leading cause of preventable death in the United States (after smoking, high blood pressure, and obesity). According to the CDC, excessive alcohol use led to approximately 88,000 deaths and 2.5 million years of potential life lost (YPLL) each year in the United States from 2006 – 2010.[1, 2] The economic costs of excessive alcohol consumption in 2010 were estimated at $249 billion, or $2.05 a drink.[3] The image below details deaths while intoxicated.

Deaths while intoxicated. Data from the National I Deaths while intoxicated. Data from the National Institute on Alcohol Abuse and Alcoholism (NIAAA).

Signs and symptoms

The diagnosis of an alcohol problem is best made by the history. Screening instruments for alcohol problems include the CAGE ([need to] cut down [on drinking], annoyance, guilt [about drinking], [need for] eye-opener) questionnaire and the AUDIT (alcohol use disorders identification test). The CAGE questions should be given face-to-face, whereas AUDIT can be given as a paper-and-pencil test.

The following are signs and symptoms of alcohol withdrawal:

  • Nausea and vomiting
  • Diaphoresis
  • Agitation and anxiety
  • Headache
  • Tremor
  • Seizures
  • Visual and auditory hallucinations: Many patients who are not disoriented—and who therefore do not have delirium tremens—have hallucinations

The following are signs of delirium tremens (ie, alcohol withdrawal delirium):

  • Tachycardia and hypertension
  • Temperature elevation
  • Delirium

The following are signs of chronic alcoholism:

  • Gynecomastia
  • Spider angiomata
  • Dupuytren contractures (also may be congenital)
  • Testicular atrophy
  • Enlarged or shrunken liver
  • Enlarged spleen

Complications of alcoholism manifest as follows:

  • Wernicke encephalopathy: Ataxia, ophthalmoplegia (usually lateral gaze palsy), and confusion
  • Korsakoff syndrome: Anterograde and retrograde amnesia, often with confabulation and preceded by Wernicke encephalopathy
  • Hepatic encephalopathy: Asterixis and confusion

See Clinical Presentation for more detail.

Diagnosis

Alcohol biomarkers are physiologic indicators of alcohol exposure or ingestion and may reflect the presence of an alcohol use disorder. These biomarkers are not meant to be a substitute for a comprehensive history and physical examination. Indirect alcohol biomarkers, which suggest heavy alcohol use by detecting the toxic effects of alcohol, include the following[4] :

  • Aspartate aminotransferase (AST)
  • Alanine aminotransferase (ALT)
  • Gamma glutamyltransferase (GGT)
  • Mean corpuscular volume (MCV)
  • Carbohydrate-deficient transferrin (CDT)

Direct alcohol biomarkers include alcohol itself and ethyl glucuronide (EtG).[4] A blood alcohol level detects alcohol intake in the previous few hours and thus is not necessarily a good indicator of chronic excessive drinking.[5] Blood alcohol levels that indicate alcoholism with a high degree of reliability are as follows:

  • >300 mg/dL in a patient who appears intoxicated but denies alcohol abuse
  • >150 mg/dL without gross evidence of intoxication
  • >100 mg/dL upon routine examination

Features of EtG are as follows:

  • Becomes positive shortly after intake of alcohol, even in small amounts [5]
  • After complete cessation of alcohol intake, EtG can be detected in urine for up to 5 days after heavy binge drinking [6, 7]

See Workup for more detail.

Management

The first step in treatment is brief intervention.

Further treatment of alcoholism involves the following:

  • Complete abstinence is the only treatment for alcohol dependence
  • Emphasize that the most common error is underestimating the amount of help needed to stop drinking
  • Hospitalize patients if they have a history of delirium tremens or if they have significant comorbidity
  • Consider inpatient treatment if the patient has poor social support, significant psychiatric problems, or a history of relapse after treatment
  • Strongly recommend Alcoholics Anonymous (AA)
  • Encourage hospitalized patients to call AA from the hospital; AA will send someone to talk to them if the patient makes the contact
  • Patients need to attend AA meetings regularly (daily at first) and for a sufficient length of time (usually 2 years or more) because recovery is a difficult and lengthy process
  • In the beginning of treatment, and perhaps ongoing, patients should remove alcohol from their homes and avoid bars and other establishments where strong pressures to drink may hinder abstinence
  • If the patient has an antisocial personality (ie, severe problems with family, peers, school, and police before age 15 years and before the onset of alcohol problems), recovery is less likely
  • If the patient has primary depression, anxiety disorder, or another potentially contributory disorder (the other disorder must antedate the problems with alcohol or it must be a significant problem during long periods of sobriety), treat this primary problem aggressively

See Treatment and Medication for more detail.

Next

Background

Alcoholism is common, serious, and expensive. Physicians encounter alcohol-related cirrhosis, cardiomyopathy, pancreatitis, and gastrointestinal bleeding, as well as intoxication and alcohol addiction, on a daily basis. Alcoholism is also associated with many cancers. Wernicke encephalopathy and Korsakoff psychosis are also important causes of chronic disability as well as dementia. Fetal alcohol syndrome is a leading cause of mental retardation. In addition, accidents (especially automobile), depression, dementia, suicide, and homicide are important consequences of alcoholism.

Alcohol-related diseases are discussed in separate articles. The focus of this article is screening, diagnosis, treatment, and new research findings on the natural history and heritability of alcoholism.

The following image details deaths while intoxicated.

Deaths while intoxicated. Data from the National I Deaths while intoxicated. Data from the National Institute on Alcohol Abuse and Alcoholism (NIAAA).
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Pathophysiology

Alcohol affects virtually every organ system in the body and, in high doses, can cause coma and death. It affects several neurotransmitter systems in the brain, including opiates, GABA, glutamate, serotonin, and dopamine. Increased opiate levels help explain the euphoric effect of alcohol, while its effects on GABA cause anxiolytic and sedative effects.

Alcohol inhibits the receptor for glutamate. Long-term ingestion results in the synthesis of more glutamate receptors. When alcohol is withdrawn, the central nervous system experiences increased excitability. Persons who abuse alcohol over the long term are more prone to alcohol withdrawal syndrome than persons who have been drinking for only short periods. Brain excitability caused by long-term alcohol ingestion can lead to cell death and cerebellar degeneration, Wernicke-Korsakoff syndrome, tremors, alcoholic hallucinosis, delirium tremens, and withdrawal seizures. Opiate receptors are increased in the brains of recently abstinent alcoholic patients, and the number of receptors correlates with cravings for alcohol.

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Frequency

United States

These statistics are based on the US National Longitudinal Alcohol Epidemiologic Study. Alcoholism is prevalent in 20% of adult hospital inpatients. One in 6 patients in community-based primary care practices had problem drinking. The following apply to the US adult population:

  • Current drinkers - 44%
  • Former drinkers - 22%
  • Lifetime abstainers - 34%
  • Abuse and dependency in the past year - 7.5-9.5%
  • Lifetime prevalence - 13.5-23.5%

Alcoholism is slightly more common in lower income and less educated groups. Vaillant studied the natural history of alcoholism and the differences between college-educated and inner-city alcoholic persons. He followed 2 cohorts (over 400 patients) of alcoholic patients over many years.[8]

According to Vaillant's research, inner-city men began problem drinking approximately 10 years earlier than college graduates (age 25-30 y vs age 40-45 y). Inner-city men were more likely to be abstinent from alcohol consumption than college graduates (30% vs 10%) but more likely to die from drinking (30% vs 15%). A large percentage of college graduates alternated between controlled drinking and alcohol abuse for many years. Returning to controlled drinking from alcohol abuse is uncommon, no more than 10%; however, this figure is likely to be high because it was obtained from self-reported data. Mortality in both groups was related strongly to smoking. Abstinence for less than 5-6 years did not predict continued abstinence (41% of men abstinent for 2 y relapsed).

The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) study suggests the transition from use to dependence was highest for nicotine users, followed by cocaine, alcohol, and cannabis users.[9] An increased risk of transition to dependence among minorities and those with psychiatric or dependence comorbidity highlights the importance of promoting outreach and treatment of these populations.

Binge drinking statistics from the CDC estimate more than 38 million US adults binge drink an average of 4 times a month and the most drinks they consume on average is 8. The report found that binge drinking is more common among households with incomes ≥$75,000, but the largest number of drinks consumed per occasion is highest among households with incomes of <$25,000.[10]

International

The World Health Organization examined mental disorders in primary care offices and found that alcohol dependence or harmful use was present in 6% of patients. In Britain, 1 in 3 patients in community-based primary care practices had at-risk drinking behavior. Alcoholism is more common in France than it is in Italy, despite virtually identical per capita alcohol consumption.

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Mortality/Morbidity

According to the CDC, excessive alcohol use led to approximately 88,000 deaths and 2.5 million years of potential life lost (YPLL) each year in the United States from 2006 – 2010.[1, 2] It is the fourth leading preventable cause of death in the United States.[2] The economic costs of excessive alcohol consumption in 2010 were estimated at $249 billion, or $2.05 a drink.[3]

In 2012, 3.3 million deaths, or 5.9 percent of all global deaths (7.6 percent for men and 4.0 percent for women), were attributable to alcohol consumption.[11] Worldwide, alcohol is responsible for a percentage of a number of conditions, as follows:

An analysis in the United Kingdom in 2010 found that overall, alcohol was found to be the most harmful drug to the person consuming and to others. However, this study does not mean that substances other than alcohol have no harmful consequences; heroin, cocaine, and methamphetamine were found to be the most harmful drugs to individuals themselves. In addition, this study did not address the issue of polydrug abuse, which is a common phenomenon in individuals abusing substances. The combination of alcohol and other substances can lead to serious adverse effects, and such combinations were not explored in this study.[12]

Below are the statistically significant relative risks from a study by the American Cancer Society for men and women who consume 4 or more drinks daily. A drink is defined as one 12-oz beer, one 4- to 5-oz glass of wine, or one mixed drink containing 1.5 oz of spirits (80 proof). The relative risk for the noted maladies with consumption of 4 or more drinks daily is as follows:

  • Cirrhosis - For men, 7.5; for women, 4.8
  • Injuries - For men, 1.3
  • Ear, nose, and throat cancer; esophagus cancer; liver cancer - For men, 2.8; for women, 3

Moderate alcohol consumption (1-2 drinks/d) reduces the risk of cardiovascular disease in men and women by approximately 30%.[13, 14, 15] The effect of heavy alcohol consumption on the risk of cardiovascular disease varies in different studies. The person's drinking pattern appears to have an effect on cardiovascular disease. Drinking with meals may reduce the risk, while binge drinking increases risk (even in otherwise moderate drinkers).

Moderate alcohol consumption appears to increase the risk of breast cancer in women. Total mortality is reduced with moderate alcohol consumption but not with heavy alcohol consumption; the cardiovascular benefit is offset by cirrhosis, cancer, and injuries. The amount of alcohol associated with the lowest mortality appears to be 2 drinks per day in men and 1 drink or fewer per day in women. Moderate alcohol consumption reduces the risk of developing diabetes, but heavy alcohol consumption may increase the risk. The cardiovascular benefit becomes important in men older than 40 years and in women older than 50 years. The risk of hypertension is increased with 3 or more drinks daily.

No benefits are noted in people at low risk for coronary disease (men < 40 y and women < 50 y). Recent data suggest an increase in coronary calcification with moderate alcohol consumption in young adults.[16] This effect was exacerbated by binge drinking.

Of men aged 18-25 years, 60% binge drink. (Binge drinking is defined as 5 alcoholic drinks for men [4 for women] in a row.) Binge drinking significantly increases the risk of injury and contracting sexually transmitted diseases. Women who binge drink at this age are at higher risk of becoming pregnant and potentially harming an unborn child. (Any amount of alcohol consumption during pregnancy is risky.) Cohort data from the Prospective Epidemiological Study of Myocardial Infarction (PRIME) investigated alcohol use patterns on ischemic heart disease in Northern Ireland and France. Regular and moderate alcohol use throughout the week, a typical pattern in middle-aged men in France, was associated with a lower risk of ischemic heart disease, whereas the binge drinking pattern more prevalent in Northern Ireland was associated with a higher risk of ischemic heart disease.[17]

More than three quarters of all foster children in the United States are children of alcohol- or drug-dependent parents. From 60-70% of reported domestic violence incidents involve alcohol. Half of all violent crime is alcohol or drug related.

Overall, morbidity and mortality are related strongly to smoking, and people who drink heavily are less likely to quit smoking. Additionally, persons who begin smoking early are more likely to develop problems with alcohol.

With regard to pregnancy, fetal alcohol syndrome is the leading known cause of mental retardation (1 in 1000 births). More than 2000 infants annually are born with this condition in the United States. Alcohol-related birth defects and neurodevelopmental problems are estimated to be 3 times higher. Even small amounts of alcohol consumption may be risky in pregnancy. A 2001 study by Sood et al reported that children aged 6-7 years whose mothers consumed alcohol even in small amounts had more behavioral problems.[18] In a study from 2003, Baer et al showed that moderate alcohol consumption while pregnant resulted in a higher incidence of offspring problem drinking at age 21 years, even after controlling for family history and other environmental factors.[19] All women who are pregnant or planning to become pregnant should avoid alcohol.

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Race

The 2 largest studies, the US National Comorbidity Survey and the Epidemiologic Catchment Area Survey, both showed a lower prevalence of alcoholism in African Americans than in white Americans. The prevalence was equal or higher in Hispanic Americans compared with white Americans.

Studies of Native Americans and Asian Americans are smaller. These studies indicate the prevalence of alcoholism is higher in Native Americans and lower in Asian Americans when compared with white Americans.

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Sex

Alcoholism is at least twice as prevalent in men as it is in women. In the National Comorbidity Survey, it was 2.5 times more prevalent in men than in women. The lifetime prevalence was 20% in men and 8% in women. For alcohol abuse or dependence in the past year, the rates were 10% for men and 4% for women.

Women do not metabolize alcohol as efficiently as men. Hazardous drinking (not alcoholism) is greater than 1 drink daily for women and greater than 2 drinks daily for men.

Problem drinking in women is much less common than it is in men, and the typical onset of problem drinking in females occurs later than in males. However, progression is more rapid, and females usually enter treatment earlier than males. Women more commonly combine alcohol with prescription drugs of abuse than do males. Women living with substance-abusing men are at high risk.

Alcohol problems are less likely to be recognized in women, and women with alcohol problems are less likely to be treated. This may be because women are less likely than men to have job, financial, or legal troubles as a result of drinking.

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Age

The prevalence of alcoholism declines with increasing age. The prevalence in elderly populations is unclear but is probably approximately 3%. A study of the US Medicare population found that alcohol-related hospitalizations were as common as hospitalizations for myocardial infarction.

Because of the growing population of older Americans, the number of heavy drinkers will increase from 1 million currently to 2 million by 2060.[20] The 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions III (NESARC III) found that 55.2% of adults age 65 and over drink alcohol. Most of them don’t have a drinking problem, but some of them drink above the recommended daily limits.[21]

Among older patients with alcoholism, from one third to one half develop alcoholism after age 60 years. This group is harder to recognize. A population-based study found that problem drinking (>3 drinks/d) was observed in 9% of older men and in 2% of older women. Alcohol levels are higher in elderly patients for a given amount of alcohol consumed than in younger patients.

Among younger individuals (such as college students), weekly or daily consumption of energy drinks (highly caffeinated beverages) has been strongly associated with alcohol dependence. This population is an important target population for alcohol use disorder prevention.[22]

 

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Contributor Information and Disclosures
Author

Warren Thompson, MD, FACP Associate Professor, Department of Internal Medicine, Mayo Medical School

Warren Thompson, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, American Heart Association, Phi Beta Kappa

Disclosure: Nothing to disclose.

Coauthor(s)

R Gregory Lande, DO, FACN Clinical Consultant, Army Substance Abuse Program, Department of Psychiatry, Walter Reed Army Medical Center

R Gregory Lande, DO, FACN is a member of the following medical societies: American Osteopathic Academy of Addiction Medicine, American Osteopathic Association

Disclosure: Nothing to disclose.

Raj K Kalapatapu, MD Fellow, Addiction Psychiatry, Columbia University College of Physicians and Surgeons

Raj K Kalapatapu, MD is a member of the following medical societies: American Academy of Addiction Psychiatry, American Academy of Child and Adolescent Psychiatry, American Association for Geriatric Psychiatry, American Medical Association, American Psychiatric Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Iqbal Ahmed, MBBS, FRCPsych(UK) Faculty, Department of Psychiatry, Tripler Army Medical Center; Clinical Professor of Psychiatry, Uniformed Services University of the Health Sciences; Clinical Professor of Psychiatry, Clinical Professor of Geriatric Medicine, University of Hawaii, John A Burns School of Medicine

Iqbal Ahmed, MBBS, FRCPsych(UK) is a member of the following medical societies: Academy of Psychosomatic Medicine, American Neuropsychiatric Association, American Society of Clinical Psychopharmacology, Royal College of Psychiatrists, American Association for Geriatric Psychiatry, American Psychiatric Association

Disclosure: Nothing to disclose.

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Deaths while intoxicated. Data from the National Institute on Alcohol Abuse and Alcoholism (NIAAA).
Table 1. AUDIT Questions and Scoring System
Questions 0 Points 1 Point 2 Points 3 Points 4 Points
1. How often do you have a drink containing alcohol? Never Monthly or less 2-4 times a month 2-3 times a week 4 or more times a week
2. How many drinks containing alcohol do you have on a typical day when you are drinking? 1 or 2 3 or 4 5 or 6 7-9 10 or more
3. How often do you have 6 or more drinks on 1 occasion? Never Less than monthly Monthly Weekly Daily or almost daily
4. How often during the past year have you found that you were not able to stop drinking once you had started? Never Less than monthly Monthly Weekly Daily or almost daily
5. How often during the past year have you failed to do what was normally expected of you because of drinking? Never Less than monthly Monthly Weekly Daily or almost daily
6. How often during the past year have you needed a first drink in the morning to get yourself going after a heavy drinking session? Never Less than monthly Monthly Weekly Daily or almost daily
7. How often during the past year have you had a feeling of guilt or remorse after drinking? Never Less than monthly Monthly Weekly Daily or almost daily
8. How often during the past year have you been unable to remember what happened the night before because you had been drinking? Never Less than monthly Monthly Weekly Daily or almost daily
9. Have you or has someone else been injured as a result of your drinking? No   Yes, but not in the past year   Yes, during the past year
10. Has a relative, friend, or a doctor or other health care worker been concerned about your drinking or suggested you cut down? No   Yes, but not in the past year   Yes, during the past



year



Table 2. Sensitivity and Specificity of Alcohol Biomarkers*
Biomarker Sensitivity (%) Specificity (%)
AST 15-69 47-68
ALT 18-58 50-57
GGT 34-85 11-95
MCV 34-89 26-95
CDT 39-94 82-100
CDT + GGT 90 † 98
Alcohol 0-100 0-100
EtG 76-91 77-92
*Values vary considerably according to gender, age, drinking pattern, prevalence of alcohol abuse/dependence, and prevalence of comorbidity, among other factors.[39, 6, 40, 42, 43]



† The sensitivity comes from one study in Finland, which uses a special formula. This study needs to be replicated.[44]



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