Introduction to Alcoholism

A chronic disorder, alcoholism is usually described as an uncontrolled intake of alcoholic beverages that interferes with physical and mental health, social and family relationships, and occupational responsibilities. Alcoholism cuts across all social and economic groups, involves both sexes, and occurs at all stages of the life cycle, beginning as early as elementary school age. About 20% of patients, even in affluent areas, have alcoholism. Lifetime risk for dependence is 10% to 15% for men and 5% for women.

Causes
Numerous biological, psychological, and sociocultural factors appear to be involved in alcohol addiction. An offspring of one alcoholic parent is seven to eight times more likely to become an alcoholic than is a peer without an alcoholic parent. Biological factors include genetic and biochemical abnormalities, nutritional deficiencies, endocrine imbalances, and allergic responses.
Psychological factors include the urge to drink alcohol to reduce anxiety or symptoms of mental illness; the desire to avoid responsibility in family, social, and work relationships; and the need to bolster self-esteem.
Sociocultural factors include the availability of alcoholic beverages, peer pressure, an excessively stressful lifestyle, and social attitudes that approve of frequent drinking.

Signs and symptoms
Because people with alcohol dependence may hide or deny their addiction and may temporarily manage to maintain a functional life, assessing a patient for alcoholism can be difficult. However, there are various physical and psychosocial symptoms that can facilitate assessment.
The patient’s history may suggest a need for daily or episodic alcohol use to maintain adequate functioning, an inability to discontinue or reduce alcohol intake, episodes of anesthesia or amnesia (blackouts) during intoxication, episodes of violence during intoxication, or interference with social and familial relationships and occupational responsibilities.
Many minor complaints that the patient may have may also be alcohol related. He may mention malaise, dyspepsia, mood swings, depression, or more infections. Note any evidence of an unusually high tolerance for sedatives and narcotics.
Secretive behavior is another indication. When confronted, the patient may deny or rationalize his problem with alcohol. Alternatively, he may be guarded or hostile in his response. He also may project his anger or feelings of guilt or inadequacy onto others to avoid confronting his illness.
With chronic alcohol abuse, the patient may experience malnutrition, cirrhosis of the liver, peripheral neuropathy, brain damage, or cardiomyopathy.
After abstaining from alcohol or significantly reducing his intake, the patient may experience signs and symptoms of withdrawal, and they may last for 5 to 7 days. The patient initially experiences anorexia, nausea, anxiety, fever, insomnia, diaphoresis, and tremor, progressing to severe tremulousness, agitation and, possibly, hallucinations and violent behavior. Major tonic-clonic seizures (known as rum fits) can occur during withdrawal. Suspect alcoholism in any patient with unexplained seizures.

Diagnosis
Laboratory values may help support the diagnosis of alcoholism—for example, they can confirm alcohol use and complications and indicate recent alcohol ingestion:

• Blood alcohol level of 0.10% weight/volume (200 mg/dl) is accepted as the level of intoxication.
• Blood urea nitrogen level rises in severe hepatic disease.
• Blood glucose level is decreased.
• Serum ammonia and amylase levels are increased.
• Urine toxicology studies may help detect other types of drug abuse in patients with alcohol withdrawal delirium or another acute complication.
• Liver function studies reveal increased levels of serum cholesterol, lactate dehydrogenase, alanine aminotransferase, aspartate aminotransferase, and creatine kinase (which indicate liver damage) and elevated serum amylase and lipase levels (which indicate acute pancreatitis).
• Blood studies may identify anemia, thrombocytopenia, increased prothrombin time, and increased partial thromboplastin time.

Treatment
Total abstinence from alcohol is the only effective treatment. Supportive programs that offer detoxification, rehabilitation, and aftercare, including continued involvement in Alcoholics Anonymous, may produce good long-term results.

Acute intoxication is treated symptomatically by supporting respiration, preventing aspiration of vomitus, replacing fluids, administering I.V. glucose to prevent hypoglycemia, correcting hypothermia or acidosis, and initiating emergency treatment for trauma, infection, or GI bleeding. 

Acute withdrawal is also treated with oral multiple B vitamins, including thiamine. Administer fluids as needed, but avoid overhydrating the patient.

Treatment of chronic alcoholism involves counseling, education, and cognitive techniques; psychotherapy (consisting of behavior modification techniques, group therapy, and family therapy); and appropriate measures to relieve associated physical problems.
Aversion, or deterrent, therapy may involve a daily oral dose of disulfiram to prevent compulsive drinking. (See Avoiding the risks of disulfiram therapy.)
Tranquilizers, particularly the benzodiazepines, are used to decrease withdrawal symptoms of the central nervous system and are administered routinely to decrease risk of seizures. These drugs are administered and decreased over 3 to 5 days. Status epilepticus should be treated aggressively; initial treatment with lorazepam I.V. is effective.
Supportive counseling or individual, group, or family psychotherapy may help. Ongoing support groups are also helpful