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* This is the Professional Version. *

Alcohol Use Disorders and Rehabilitation

By Gerald F. O’Malley, DO, Thomas Jefferson University and Hospital ; Rika O’Malley, MD

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Patient Education

Alcohol use disorder involves a pattern of alcohol use that typically includes craving and manifestations of tolerance and/or withdrawal along with adverse psychosocial consequences. Alcoholism and alcohol abuse are common but less rigorously defined terms applied to people with problems related to alcohol.

Alcohol use disorder is quite common. It is estimated to be present in 8.5% of adults in the US in any 12-mo period. Among people age 18 to 29 yr, estimated 12-mo prevalence is 16.2%.

At-risk drinking is defined solely by quantity and frequency of drinking:

  • > 14 drinks/wk or 4 drinks per occasion for men

  • > 7 drinks/wk or 3 drinks per occasion for women

Compared with lesser amounts, these amounts are associated with increased risk of a wide variety of medical and psychosocial complications.

Etiology

The maladaptive pattern of drinking that constitutes alcohol abuse may begin with a desire to reach a state of feeling high. Some drinkers who find the feeling rewarding then focus on repeatedly reaching that state. Many who abuse alcohol chronically have certain personality traits: feelings of isolation, loneliness, shyness, depression, dependency, hostile and self-destructive impulsivity, and sexual immaturity.

Alcoholics may come from a broken home and have a disturbed relationship with their family. Societal factors—attitudes transmitted through the culture or child rearing—affect patterns of drinking and consequent behavior. However, such generalizations should not obscure the fact that alcohol use disorders can occur in anyone, regardless of their age, sex, background, ethnicity, or social situation. Thus, clinicians should screen for alcohol problems in all patients.

Genetic factors

As much as 40 to 60% of risk variance is thought to be due to genetic factors. The incidence of alcohol abuse and dependence is higher in biologic children of people with alcohol problems than in adoptive children, and the percentage of biologic children of alcoholics who are problem drinkers is greater than that of the general population. There is evidence of genetic or biochemical predisposition, including data that suggest some people who become alcoholics are less easily intoxicated; ie, they have a higher threshold for CNS effects.

Symptoms and Signs

Serious social consequences usually occur. Frequent intoxication is obvious and destructive; it interferes with the ability to socialize and work. Injuries are common. Eventually, failed relationships and job loss due to absenteeism may result.

People may be arrested because of alcohol-related behavior or be apprehended for driving while intoxicated, often losing driving privileges for repeated offenses; in most US states, the maximum legal blood alcohol concentration (BAC) while driving is 80 mg/dL (0.08%), and this level is likely to be reduced in the future.

Diagnosis

  • Clinical evaluation

  • Screening

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) considers alcohol use disorder to be present if patients have clinically significant impairment or distress as manifested by the presence of ≥ 2 of the following over a 12-mo period:

  • Taking alcohol in larger amounts or for a longer time than intended

  • Persistently desiring or unsuccessfully attempting to decrease alcohol use

  • Spending a great deal of time obtaining, using, or recovering from alcohol

  • Craving alcohol

  • Failing repeatedly to meet obligations at work, home, or school because of alcohol

  • Continuing to use alcohol despite having recurrent social or interpersonal problems because of alcohol

  • Giving up important social, work, or recreational activities because of alcohol

  • Using alcohol in physically hazardous situations

  • Continuing to use alcohol despite having a physical (eg, liver disease) or mental disorder (eg, depression) caused or worsened by alcohol

  • Having tolerance to alcohol

  • Having alcohol withdrawal symptoms or drinking alcohol because of withdrawal

Screening

Some alcohol-related problems are diagnosed when people seek medical treatment for their drinking or for obvious alcohol-related illness (eg, delirium tremens, cirrhosis). However, many of these people remain unrecognized for a long time. Female alcoholics are, in general, more likely to drink alone and are less likely to manifest some of the social signs. Therefore, many governmental and professional organizations recommend alcohol screening during routine health care visits.

A scaled approach (see Levels of Screening for Alcohol Problems) can help identify patients who require more detailed questioning. Several validated detailed questionnaires are available, including the AUDIT (Alcohol Use Disorders Identification Test) and the CAGE questionnaire.

Levels of Screening for Alcohol Problems

Screening Level

Criteria for Use

Screening Technique

1

If only one question is possible

On any single occasion during the past 3 mo, have you had > 5 drinks* containing alcohol?

2

For all patients who report drinking alcohol if time allows

or

For patients who respond “yes” to a level 1 screening question

  • On average, how many days per week do you drink alcohol?

  • On a typical day when you drink, how many drinks do you have?

  • What is the maximum number of drinks you had on any given day in the past month?

3

If level 2 screening identifies risk of alcohol-related problems (ie, for men, > 14 drinks/wk or 4 drinks/day; for women, > 7 drinks/wk or 3 drinks/day)

or

If the clinician suspects that patients are minimizing their alcohol use

The 10-question Alcohol Use Disorders Identification Test (AUDIT)

*A drink is defined as 12 oz of beer, 5 oz of wine, or 1.5 oz of distilled spirits.

Adapted from Fleming MF: Screening and brief intervention in primary care settings. Available at the National Institute on Alcohol Abuse and Alcoholism (NIAAA) web site.

Treatment

  • Rehabilitation programs

  • Outpatient counseling

  • Self-help groups

  • Consideration of drugs (eg, naltrexone, disulfiram, acamprosate)

All patients should be counseled to decrease their alcohol use to below at-risk levels.

For patients identified as at-risk drinkers, treatment may begin with a brief discussion of the medical and social consequences and a recommendation to reduce or cease drinking, with follow-up regarding compliance (see Brief Interventions for Alcohol Problems).

Brief Interventions for Alcohol Problems

Intervention Level

Criteria for Use

Brief Intervention Technique

1

If screening results determine that intervention is necessary but time is limited

Simply stating concern that the patient’s drinking exceeds recommended limits and could lead to alcohol-related problems; recommending that the patient minimize or stop drinking

2

If referral to a specialist is not necessary; if abstinence is not necessarily the goal

Project TrEAT (Trial for Early Alcohol Treatment) protocol: 2 brief face-to-face sessions scheduled 1 mo apart, with a follow-up telephone call 2 wk after each session

3

If the patient has symptoms of alcohol abuse or dependence; if abstinence is the primary goal

Motivational enhancement; referral to a specialist

For patients with more serious problems, particularly after less intensive measures have been unsuccessful, a rehabilitation program is often the best approach. Rehabilitation programs combine psychotherapy, including one-on-one and group therapy, with medical supervision. For most patients, outpatient rehabilitation is sufficient; how long patients remain enrolled in programs varies, typically weeks to months, but longer if needed.

Inpatient rehabilitation programs are reserved for patients with more severe alcohol dependence and those with significant and comorbid medical, psychoactive, and substance abuse problems. Treatment duration is usually briefer (typically days to weeks) than that of outpatient programs and may be dictated in part by patients’ insurance.

Psychotherapy involves techniques that enhance motivation and teach patients to avoid circumstances that precipitate drinking. Social support of abstinence, including the support of family and friends, is important.

Maintenance

Maintaining sobriety is difficult. Patients should be warned that after a few weeks, when they have recovered from their last bout, they are likely to find an excuse to drink. They should also be told that although they may be able to practice controlled drinking for a few days or, rarely, a few weeks, they will most likely lose control eventually.

In addition to the counseling provided in outpatient and inpatient alcohol treatment programs, self-help groups and certain drugs may help prevent relapse in some patients.

Alcoholics Anonymous (AA) is the most common self-help group. Patients must find an AA group they feel comfortable in. AA provides patients with nondrinking friends who are always available and a nondrinking environment in which to socialize. Patients also hear others discuss every rationalization they have ever used for their own drinking. The help they give other alcoholics may give them the self-regard and confidence formerly found only in alcohol. Many alcoholics are reluctant to go to AA and find individual counseling or group or family treatment more acceptable. Alternative organizations, such as LifeRing Secular Recovery (Secular Organizations for Sobriety), exist for patients seeking another approach.

Drug therapy should be used with counseling rather than as sole treatment. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) provides a guide for clinicians on medical management and pharmacotherapy for alcohol dependence along with a number of other publications and resources for both health care practitioners and patients.

Disulfiram, the first drug available to prevent relapse in alcohol dependence, interferes with the metabolism of acetaldehyde (an intermediary product in the oxidation of alcohol) so that acetaldehyde accumulates. Drinking alcohol within 12 h of taking disulfiram causes facial flushing in 5 to 15 min, then intense vasodilation of the face and neck with suffusion of the conjunctivae, throbbing headache, tachycardia, hyperpnea, and sweating. With high doses of alcohol, nausea and vomiting may follow in 30 to 60 min and may lead to hypotension, dizziness, and sometimes fainting and collapse. The reaction can last up to 3 h. Few patients risk drinking alcohol while taking disulfiram because of the intense discomfort. Drugs that contain alcohol (eg, tinctures; elixirs; some OTC liquid cough and cold preparations, which contain as much as 40% alcohol) must also be avoided.

Disulfiram is contraindicated during pregnancy and in patients with cardiac decompensation. It may be given on an outpatient basis after 4 or 5 days of abstinence. The initial dosage is 0.5 g po once/day for 1 to 3 wk, followed by a maintenance dosage of 0.25 g once/day. Effects may persist for 3 to 7 days after the last dose. Periodic physician visits are needed to encourage continuation of disulfiram as part of an abstinence program.

Disulfiram’s general usefulness has not been established, and many patients are nonadherent. Adherence usually requires adequate social support, such as observation of drinking. For these reasons, use of disulfiram is now limited. Disulfiram is most effective when given under close supervision to highly motivated patients.

Naltrexone, an opioid antagonist, decreases the relapse rate and number of drinking days in most patients who take it consistently. Naltrexone 50 mg po once/day is typically given, although there is evidence that higher doses (eg, 100 mg once/day) may be more effective in some patients. Even with counseling, adherence rates with oral naltrexone are modest. A long-acting depot form is also available: 380 mg IM once/mo. Naltrexone is contraindicated in patients with acute hepatitis or liver failure and in those who are opioid dependent.

Acamprosate, a synthetic analogue of gamma-aminobutyric acid, is given as 2 g po once/day. Acamprosate may decrease the relapse rate and number of drinking days in patients who relapse.

Nalmefene, an opioid antagonist, and topiramate are under study for their ability to decrease alcohol craving.

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* This is the Professional Version. *