Alcohol causes as much harm as smoking and hypertension. Abuse implies that repeated drinking harms a person's work or social life. Addiction implies:
- Difficulty or failure of abstinence
- Narrowing of drinking repertoire
- Increased tolerance to alcohol
- Often aware of compulsion to drink
- Priority is to maintain alcohol intake
- Sweats, nausea, or tremor on withdrawal
Ask about tolerance, worry about drinking, eye opener drinks used in the mornings, amnesia from alcohol use, and attempts to cut down. 2 points is TWEAK +ve (?more sensitive than CAGE questions).
Alcohol & organ damage Liver:
(normal in 50% of alcoholics). Fatty liver: Acute, reversible; hepatitis; 80% progress to cirrhosis (liver failure in 10%) Cirrhosis: 5yr survival 48% if alcohol intake continues (if it stops, 77%).
CNS
Poor memory/cognition; cortical/cerebellar atrophy; retrobulbar neuropathy; fits; falls; accidents; neuropathy; Korsakoff's/Wernicke's encephalopathy (OHCM; urgent parenteral vitamins are needed).
Gut
D&V; peptic ulcer; erosions; varices; pancreatitis.
Marrow
Hb; MCV.
Heart
Arrhythmias; BP; cardiomyopathy; fewer MIs (?benefit only if [greater than or equivalent to]55yrs).
Skeleton
Heavy drinking disrupts calcium metabolism (osteoporosis risk).
Malignancy
GI & breast.
Social
Alcohol is related to violent crime & suicide.
Alcohol & drug levels
Regular heavy drinking induces hepatic enzymes; binging inhibits enzymes; it's probably not a good idea to indulge in both and hope for the best. Be alert with phenytoin, warfarin, tolbutamide, etc. NB: paracetamol may cause N-acetyl-p-benzoquinoneimine (it is hepatotoxic).
Withdrawal signs
(Delirium tremens) Pulse; BP; tremor; fits; visual or tactile hallucinations, eg of crawling animals. Treatment:
- Admit; monitor vital signs (beware BP).
- For the 1st 3 days give diazepam generously, eg 10mg/6h PO or PR if vomitingor IVI during fits, Chlordiazepoxide is an alternative. After a few days, diazepam (eg 10mg/8h PO from day 4-6, then 5mg/12h PO for 2 more days). blockers, clonidine, carbamazepine, and neuroleptics (if no liver damage) are adjuncts (not advised as monotherapy).
Treatment
Key determinants of success are the patient's commitment and willingness to undergo treatmentso it is worth taking time to explore concordance between your own ideas and those of your patient.
Treat co-existing depression. Refer to specialists. Group psychotherapy/self-help groups (Alcoholics Anonymous) may help, agents which produce an unpleasant reaction if alcohol is taken (eg disulfiram 800mg stat then to 100-200mg/24h PO over 5 days). Reducing the pleasure that alcohol brings (and craving on withdrawn) with naltrexone 25-50mg/24h PO (an opioid receptor antagonist) can halve relapse rates.172 [N=111] SE: vomiting, drowsiness, dizziness, cramps, joint pain. CI: hepatitis; liver failure. Liaise with experts on its best use. Acamprosate (OHCM) can treble abstinence rates. CI: pregnancy, severe liver failure, creatinine >120 µmol/L; SE: D&V, libido fluctuation; dose example: 666mg/8h PO if >60kg and <65yrs old. Economic analysis supports its use, at least in some communities.
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