Information arranged from JHH learning modules

1. Alcoholism and
Unhealthy
Alcohol Use –
2013
Information by Johns Hopkins
Medicine Internet Learning
Center
Arranged By: Benjamin
Tabibian DO

2. Why this module?

3. Health Effects of Alcohol
 Question 1
 Mr. Stubbs is a 50 year-old executive who
is brought to the emergency department
after his car hit a tree. He says he was on
his way home from a party where he had
two glasses of wine with dinner. He is
awake, alert and oriented, but somewhat
irritable. His blood alcohol level is 112
mg/dL

4. Health Effects of Alcohol
 a).His blood alcohol level is consistent with drinking
two glasses of wine.
 b).He is not legally intoxicated.
 c).His blood alcohol level is equivalent to a BAC of
1.12%.
 d).His blood alcohol level would cause a
significant impairment in reflexes and reaction
time.

5. Health Effects of Alcohol
 ETOH is the most common substance of
abuse
 1 unit is commonly thought of as
 12oz beer
 5oz wine
 1.5oz shot

7. Health Effects of Alcohol
 The acute effect of a given amount of alcohol on an
individual will vary depending on a number of
factors:
 Weight (higher weight, less impact).
 Gender (women tend to be affected more).
 Genetics (variations in absorption and metabolism).
 Rapidity of consumption (faster consumption leads to
higher levels).
 Presence of food in the stomach (slows absorption).
 Tolerance (those who consume alcohol regularly
develop a tolerance to the effects and metabolize
alcohol more rapidly).

8.  BAC of 0.08% (80 mg/dL) or higher is considered
intoxicated (in the USA)
 general rule of thumb is that two standard drinks will
increase the average person's blood alcohol
concentration by roughly 50 mg/dL (0.05%),
therefore one would generally need to consume at
least 3 drinks to be over this threshold.
 10-15 mg/dL per hour; those who abuse alcohol
chronically generally metabolize it at a higher rate
of about 20-30 mg/dL per hour
 risk of death with blood alcohol concentrations over
300 mg/dL

10. The Abuser
 Signs of a pt presenting
 Odor of etoh
 Slurred speech
 Having just consumed prior to visit
 Having signs of withdrawal because they chose
to obtain
 Multiple traumatic injuries
 work or family problems, depression, anxiety,
sleep disorders, gastrointestinal problems, sexual
dysfunction, heavy cigarette smoking and
family history of alcoholism
 Blood test abnormalities

11. Withdrawal

13. However…
 moderate alcohol consumption has not
been shown to have deleterious health
effects; in fact, it is associated with a
reduced risk of a number of medical
problems, including heart disease (5),
type II diabetes (6), and dementia

14. Diagnosis
 Mr. Stubbs, our 50 year-old executive, sees you for
a routine physical exam after his car accident
when he was legally intoxicated. He has no
current complaints. Past medical history is notable
for an episode of paroxysmal atrial fibrillation four
years ago, which has not since recurred. Family
history is notable for a mother with hypertension;
his father died of liver failure. When you question
him about his alcohol use, he tells you he has "a
few drinks" each night, typically vodka martinis.
When you try to quantify this further, the patient
states that he does not feel that this is a problem
and changes the subject.

15.  a).Men typically under report their quantity of
alcohol intake.
 b).The diagnosis of "alcoholism" requires that an
individual has developed some level of tolerance to
alcohol.
 c).Denial is a characteristic of alcoholism.
 d).Someone who has driven while intoxicated
meets the criteria for unhealthy alcohol use.

16.  According to the 2010 National Survey on Drug Use
and Health (NSDUH), among Americans aged 12
and older, about half are current alcohol users
(drank in the last month), 23% reported binge
drinking (more than 5 drinks on one occasion in the
last month), and 7% reported heavy alcohol use
(binge drinking at least 5 of the last 30 days). An
estimated 11% drove under the influence of alcohol
at least once in the previous year; this rate was
highest among those in the 21-25 years age group
(23%)

17.  No clear line between healthy and unhealthy use…
but we can approximate
 This is per NIAA recommendations
 Men over 65 should follow women parameters

18. Alcoholism
 "primary, chronic disease with genetic,
psychosocial, and environmental factors
influencing its development and
manifestations. The disease is often
progressive and fatal. It is characterized by
impaired control over drinking,
preoccupation with the drug alcohol despite
adverse consequences, and distortions in
thinking, most notably denial. Each of these
symptoms may be continuous or periodic”

19. DSM IV creiteria must have 3/7

20. Question 3
 You continue to evaluate the business
executive presenting for a routine
evaluation. You are intrigued by his history
of atrial fibrillation in the past, and wonder
if that was related to alcohol ingestion.
Knowing that patients do not do well at
assessing the impact of alcohol on their
life, you decide to screen him with a set of
specific questions on his drinking.

21.  a).His wife complains about his drinking.
 b).He has recently cut down on his drinking.
 c).He has an eye-opener in the morning.
 d).He feels he should drink less.

22. AUDIT and CAGE
 10-item Alcohol Use Disorders
Identification Test (AUDIT)
 4-item CAGE questionnaire
 AUDIT is designed to detect unhealthy
alcohol use as well as alcoholism, while
the CAGE is designed to screen for
alcohol dependence

23. AUDIT-C
 AUDIT-C; a score of 3 or more has a
sensitivity of 98% for heavy drinking and
90% for alcohol abuse or dependence,
but a specificity of only 60% (i.e., 40%
false-positive rate).

25. CAGE
 Looking for 2 or more positive answers
 when using a cutoff of two or more
positive answers, the sensitivity was 74%
and specificity 91%; using a cutoff of one
or more positive answers increased the
sensitivity to 89% while lowering the
specificity to 81%

27. Question 4
 While your patient offers negative answers
for all four of the CAGE questions, he does
admit to having more than 5 drinks at a
party a few weeks ago.

28.  a).Counseling alone is not effective.
 b).Counseling unhealthy alcohol users is effective,
but the effect disappears after a few months.
 c).In order to be effective, counseling must be
delivered by trained mental health professionals.
 d).Brief counseling has been shown to reduce
unhealthy alcohol use for up to 4 years.

29. Counseling for Unhealthy Use
 brief counseling for unhealthy alcohol use
is effective at reducing alcohol
consumption
 Studies on people who were not alcoholics

30.  be empathic and non-judgmental, while clearly
stating your concerns and recommendations
 the goal for unhealthy drinkers is not necessarily
abstinence, but limiting alcohol consumption to
healthy levels

31. For Alcoholics
 brief advice alone has not been shown to
be effective for alcoholics
 The first step is confrontation: telling a
patient that you believe they have a
problem in an empathic manner, while
offering hope and help. The alcoholic's
initial response to confrontation is often
denial and it may take time for this to
break down

32. Question 5
 You see the business executive back, and
after a few visits and further discussion, your
patient states that his problem with alcohol is
more serious than he previously
acknowledged. He now admits that he has
been secretly drinking an "eye opener" to
prevent "the shakes". The patient is concerned
about suddenly stopping alcohol, as he has
heard stories about people dying from "the
DTs", although he has never experienced
them himself.

33.  a).If untreated, most alcoholics will have seizures or
develop delirium tremens during withdrawal.
 b).Phenothiazines are an effective alternative to
benzodiazepines for alcohol withdrawal.
 c).Alcoholics can be safely detoxified as
outpatients.
 d).He should be started on phenytoin to prevent
seizures while going through withdrawal.

34. Detoxification
 withdrawal is an important barrier to
sobriety and can, at times, be life-
threatening
 the most dangerous complications are
seizures and delirium tremens
 mild-moderate withdrawal
symptoms, detoxification can be done in
an outpatient setting

35. Delirium Tremens
 Risk factors
 Previous episodes of DT’s
 High bp or hr on presentation
 Older age
 comorbidities

36.  Recommended indications for inpatient therapy
 Moderate to severe withdrawal.
 Previous seizures or delirium tremens.
 Inability to cooperate with daily follow-up.
 Comorbid medical or psychiatric illness that requires
hospitalization.
 Inability to take medications by mouth/persistent
nausea and vomiting.
 Unsuccessful previous attempts at outpatient
detoxification.

37. Treatment
 Benzodiazepine taper
 no evidence that any particular benzodiazepine is
better than any other, but most studies utilized
diazepam, lorazepam or chlordiazepoxide
 Lorazepam may be a better choice for severe liver
disease
 No real difference between fixed dose and as
needed regements
 patients with severe alcohol withdrawal may
initially require much higher dosage for treatment
of their withdrawal
 For seizures phenytoin has not been shown to be
effective (36).

38. Question 6
 After successfully completing
detoxification, your patient comes to see
you and asks you what he should do to
prevent a relapse

39.  a).Attendance at self-help groups like AA is
associated with improved outcomes.
 b).Disulfiram (antabuse) is the best drug to prevent
relapse.
 c).Benzodiazepines have been shown to reduce
the risk of relapse.
 d).Topiramate is effective for preventing alcohol-
related seizures, but not decreasing alcohol
consumption.

40. Staying Sober
 Self-help groups, such as
Alcoholics Anonymous (AA) and
other rehabilitation programs
have traditionally been the
mainstay of maintenance of
sobriety.
 counseling (individual or group)
 psychotherapy (especially
cognitive behavioral therapy),
 residential treatment programs

41. Pharmacotherapy
 disulfiram (Antabuse)
 inhibits the metabolism of alcohol and results in
a buildup of acetaldehyde when alcohol is
consumed, leading to nausea, vomiting and
flushing
 Studies of alcoholics prescribed this agent have
failed to show lasting benefit in preventing
relapse or reducing consumption of alcohol
 associated with hepatitis and liver failure and
should not be used in patients with pre-existing
chronic liver disease

42.  Naltrexone (Revia)
 thought to attenuate craving for alcohol by blocking
endogenous opioids
 Short term studies showed moderate decrease in
consumption but questionable long term benefit
 FDA approved for treatment of alcoholism
 Acamprosate
 GABA analogue and studies suggest that it may have
modest benefit
 May be used alone or with naltrexone
 Very questionable benefit
 FDA approved for treatment of alcoholism

43.  topiramate (Topamax)
 effects on GABA transmission
 Two randomized-controlled study of this antiseizure
medication have reported a significant reduction in
alcohol consumption and increase in abstinence over
a 12-14 week period
 Not FDA approved for treatment of alcoholism
 Studies excluded cirrhotics
 Baclofen
 Effects on GABA transmission
 Only one trial but showed some promise
 placebo-controlled trial, among 84 alcoholics with
cirrhosis, those who received baclofen (10 mg three
times daily) were significantly more likely to achieve
and maintain abstinence at 12 weeks (71 vs. 29%)
 Not FDA approved