• Clinical science

Alcohol-related disorders

Summary

Alcohol-related disorders, including alcohol intoxication, alcohol use disorder (AUD), and alcohol withdrawal, are a group of conditions associated with disruptive patterns of alcohol use. Alcohol intoxication is the acute onset of behavioral and psychomotor impairment shortly after an episode of drinking. Alcohol use disorder (AUD) is characterized by clinically significant psychosocial and behavioral problems associated with alcohol use. Alcohol withdrawal develops after a sudden cessation or reduction of alcohol use in patients with a history of excessive drinking. The diagnosis of an alcohol-related disorder can be established using the DSM-5 criteria. The most important aspect of management for all alcohol-related disorders is the cessation of alcohol use. Therapeutic management is guided by the severity of the disorder.

See breakdown of ethanol for a review of alcohol metabolism pathways.

Alcohol intoxication

  • Definition: : a temporary condition in which excessive consumption of alcohol alters a person's consciousness, cognition, perception, judgment, affect, and/or behavior
  • Pathophysiology: The majority of alcohol consumed is absorbed by the proximal small intestine. Only a small amount of alcohol gets absorbed by the oral, esophageal, and/or gastric mucosa.
  • Clinical features
Mild intoxication (BAC 0.01–0.1%, < 100 mg/dL) Moderate intoxication (BAC 0.1–0.3%, 10–300 mg/dL) Severe intoxication (BAC > 0.3%; > 300 mg/dL)
  • Increased agitation, euphoria, disinhibition, urge to speak, impaired judgment
  • Unsteady gait and difficulties standing upright
  • Skin flushing
  • Mild tachycardia and hypotension
  • Pronounced disinhibition
  • Significant reduction of attention, responsiveness, alertness, and reaction time
  • Impaired vision and sound localization
  • Increasing unsteadiness of gait and slurred speech
  • Dizziness
  • Psychomotor agitation
  • Nausea and vomiting
  • Amnestic gaps (blackouts)
  • Delusions and hallucinations
  • Severe dysarthria
  • Nausea and vomiting
  • Ataxia
  • Nystagmus
  • Alcoholic coma (usually occurs at BAC levels 0.40–0.50%) including:
    • Severely impaired consciousness
    • Lack of response to external stimuli
    • Absent airway defense reflexes and respiratory depression

In the US, the maximum legal limit for driving under the influence of alcohol is a BAC of 0.08%.

Because alcohol has a long absorption time (approx. 40 min), patients with alcohol intoxication may deteriorate over time.

Haloperidol may worsen respiratory depression secondary to alcohol intoxication!

References:[1][2][3][4][5][6][7][8]

Alcohol use disorder

AUD is a chronic condition in which an uncontrolled pattern of alcohol use leads to significant physical, psychological, and social impairment or distress. Not all individuals who drink heavily develop AUD, and not all individuals with AUD have a history of heavy alcohol use.

Epidemiology

References: [11][9][12][13][14]

Etiology

  • Genetic factors
  • Neurobiological factors
  • Psychosocial factors
    • Family history of AUD [15]
    • Environmental influence: e.g., social pressure to consume alcohol

References:[12][16]

Diagnostics

Diagnosis of AUD begins with a screening test, which is followed by a confirmatory test based on patient history. Commonly used screening tests include AUDIT-C and CAGE tests. Diagnosis is confirmed if the patient history meets the DSM-V criteria for AUD.

Screening

  • AUDIT-C test
    • Three questions based on the Alcohol Use Disorders Identification Test (AUDIT)
    • Evaluation
      • Every response is given a score from 0 to 4 points.
      • The total score can range from 0 to 12.
      • A positive test suggests the presence of an alcohol use disorder.
        • ≥ 4 in men
        • ≥ 3 in women
Question Response Score
How often did you have a drink containing alcohol in the past year? Never 0
≤ Monthly 1
2–4 times a month 2
2–3 times a week 3
≥ 4 times a week 4
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
How often did you have ≥ 6 drinks on one occasion in the past year? Never 0
< Once per month 1
Monthly 2
Weekly 3
Daily or almost daily 4
  • CAGE test
    • A series of four questions (CAGE) is used to screen for AUD
      1. Cut down drinking: Have you ever felt you should cut down on your drinking?
      2. Annoyed: Have people annoyed you by criticizing your drinking?
      3. Guilty: Have you ever felt guilty about drinking?
      4. Eye-opener: Have you ever felt you needed a drink first thing in the morning (eye-opener) to steady your nerves or to overcome a hangover?
    • Every “yes” response counts as one point.
    • The CAGE test is considered positive for AUD if ≥ 2 questions are answered in the affirmative.

Diagnostic criteria (according to DSM-5)

  • 11 criteria based on the patient's history within the past 12 months
  • A diagnosis of AUD is established once ≥ 2 criteria are met.
    1. Drinking more or over a longer period than intended
    2. Tried to cut down or stop more than once, but couldn't
    3. Spends a lot of time drinking or recovering from aftereffects
    4. Strong desire to drink alcohol
    5. Drinking has a negative impact on everyday function (social, work etc)
    6. Continued drinking despite social or interpersonal problems
    7. Given up interests and activities that were important because of drinking
    8. Drinking in physically hazardous situations more than once
    9. Continued drinking despite physical or psychological problems
    10. Increasing amount of drinks to maintain same effects as before
    11. Features of withdrawal when the effects of alcohol wear off (see alcohol withdrawal below)
  • Severity
    • Mild: presence of 2–3 criteria
    • Moderate: presence of 4–5 criteria
    • Severe: presence of ≥ 6 criteria

Laboratory tests

ToAST 2 ALcohol (AST levels are at least 2 times higher than those of ALT in case of alcoholic hepatitis)

References:[17][12][16][18][19][20]

Treatment

References:[21][4][6][22][23]

Complications

Alcohol withdrawal

  • Caused by a sudden reduction or cessation of alcohol intake after a prolonged period of heavy drinking
  • Onset and duration vary among different syndromes.
  • May be assessed using the CIWA-Ar score
  • Delirium tremens is the most severe form of alcohol withdrawal.

Individuals with chronic alcohol use often develop withdrawal symptoms 48–72 hours after hospitalization because they do not have access to alcohol in the hospital.

Minor withdrawal

  • Onset: 6–36 hours after last drink
  • Clinical features
  • Duration: 24–48 hours

Withdrawal seizures

  • Onset: 6–48 hours after last drink
  • Clinical features: : brief, generalized tonic-clonic seizure (usually a single episode)

Alcoholic hallucinosis

  • Onset: 12–48 hours after last drink
  • Clinical features
  • Duration: 24–48 hours after onset

Delirium tremens

  • Definition: persistent alteration of consciousness and sympathetic hyperactivity due to alcohol withdrawal
  • Onset: most commonly occurs 48–96 hours after last drink
  • Clinical features
    • Symptoms of altered mental status
      • Impaired consciousness and disorientation
      • Visual and tactile hallucinations (usually small moving objects, e.g., mice, crawling insects)
      • Increased suggestibility
    • Symptoms of autonomic instability
    • Symptoms of neurological impairment
  • Duration: 1–5 days

In contrast to patients with alcoholic hallucinosis, patients with delirium tremens have impaired consciousness and abnormal vital signs.

Treatment

Lorazepam, Oxazepam, and Temazepam are preferred in those who drink a LOT because they are not metabolized by the liver and therefore safe in alcoholic liver disease.

In the case of alcohol withdrawal seizures, benzodiazepines are preferred over other anticonvulsants to prevent further seizures.

References:[1][2][3][4][5][6][7][8]

Alcoholic ketoacidosis

In contrast to diabetic ketoacidosis, blood glucose levels are normal or low in alcoholic ketoacidosis.

References:[1][2][3][4][5][6][7][8]

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last updated 11/25/2019
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