Alcohol abuse and dependence

Alcohol and drugs of abuse

Alcohol abuse and dependence

Definition

Regular or binge consumption of alcohol sufficient to cause physical, neuropsychiatric or social damage.

Incidence/prevalence

3–4% of the population report alcoholrelated problems.

Sex

2M : 1F

Aetiology

Various factors have been implicated:

·        Genetic factors: Evidence includes variation across racial groups and twin studies.

·        Psychiatric factors: Family history of depression, increased risk in the presence of chronic psychiatric and physical illness especially pain.

·        Social factors: Occupation, cultural and peer group pressure.

Clinical features

Alcohol abuse and alcohol dependence are classified as recognisable entities.

·        Alcohol abuse is a drinking pattern associated with social compromise such as work or school absenteeism, legal problems related to alcohol use, or continued alcohol use despite causing social or relationship problems.

·        Alcohol dependence is defined as a maladaptive pattern of use associated with tolerance and withdrawal syndrome despite significant physical and psychological problems. Patients often exhibit a stereotyped drinking pattern with alcohol consumption taking preference over other activities.

A history of alcohol consumption should be taken from all patients with consideration given to the aforementioned social consequences of heavy drinking. In addition signs of chronic liver disease and other complications may be evident.

Complications

Medical complications include gastritis, peptic ulcer disease, pancreatitis, hepatitis, cirrhosis, portal hypertension with oesophageal varices, cardiomyopathy, hypertension.

Neuropsychiatric complications: Acute withdrawal (also known as delirium tremens) within 48 hours may result in malaise, nausea, autonomic hyperactivity, tremulousness, lability, insomnia, and transient hallucinations, illusions especially visual (e.g. spiders), frequent seizures. Serious delirium tremens has a significant mortality.

Chronic dependence causes Wernicke–Korsakoff psychosis.

Other neuropsychiatric complications include dementia, peripheral neuropathy, cerebellar degeneration, alcoholic hallucinations, symptoms of depression and/or anxiety.

Social problems include job loss, marital difficulties, criminal activity and alcoholrelated accidents.

Investigations

Blood alcohol levels are of limited value, a persistently raised MCV or γGT are suggestive of continued alcohol use.

Management

1. Identification and advice at an early stage may be enough to avert serious medical, neuropsychiatric and social consequences of alcohol. Precipitating factors should be identified and psychological support/therapy instituted as appropriate.

2. Abstinence, individuals may require general support (rehydration, correction of electrolyte imbalance, complex intravenous vitamin preparations) and treatment to avoid specific complications, e.g. chlordiazepoxide in the treatment of delirium tremens and diazepam or lorazepam in the treatment of seizures.

3. Disulfiram (Antabuse) blocks metabolism resulting in acetaldehyde accumulation resulting in flushing, headache, anxiety and nausea. This may be implanted to give 6 months of treatment.

Prognosis

15% die by suicide, 30% continue to have life-long alcohol-related problems.