Alcoholism

Definition/Description

Alcoholism is a serious disease where people have an overpowering desire for the physical and mental effects of drinking alcoholic beverages.[1] The formal term for this type of abuse is alcohol dependence and is the most severe type of alcohol problem. Alcohol is the most dominant addictive agent in the United States.[2] It can be identified by four main symptoms: craving, loss of control, physical dependence and tolerance.[3]

                                                                  Image:Alcohol_Symptoms.jpg

Prevalence

Alcoholism is the most common drug abuse problem in the US, affecting more than 15 million Americans, including the adolescent and aging populations.[4]  The National Institute of Alcohol Abuse and Alcoholism reports that alcoholism affects 1 in every 12 adults in the United States and men typically more than women. They go on to say that alcohol problems are highest among young adults ages 18-29 and lowest among adults 65 and older.[3] It has also be reported that the earlier an individual starts drinking (14 or younger) the more likely they will develop alcohol related problems.[3]

Characteristics/Clinical Presentation

A very important sign that should be looked for is continued drinking, even after drinking has caused problems such as missing work, driving drunk, getting into trouble with the law, or avoid responsibilities. When three out of the following seven symptoms is experienced during a one year period, alcoholism is suspected:[5]

  • Neglect of activities – important activities are given up because of alcohol
  • Excessive use – large amounts of alcohol is consumed over a period of time
  • Impaired control – cannot quit on own
  • Persistence of use – consumption is continued despite knowing it is a problem
  • Large amounts of time spent in alcohol related activities
  • Withdrawal – experience nausea, vomiting, sweating, shakiness, and anxiety with alcohol is stopped
  • Tolerance – increasing amount in order to feel effect

Other signs and symptoms of alcoholism may include:[6][7]

  • Drinking alone or in secret
  • "Blacking out"
  • Keeping alcohol in unlikely places
  • Feeling a need/compulsion to drink
  • Becoming intoxicated intentionally
  • Abdominal pain
  • Confusion
  • Episodes of violence with drinking
  • Hostility when confronted about drinking
  • Making excuses to drink
  • Need for daily/regular alcohol use to function
  • Neglecting to eat
  • Not caring about physical appearance
  • Numbness & tingling
  • Shaking in the morning

Alcohol is also a central nervous system depressant. This leads to a decrease in:[7]

  • Activity
  • Anxiety
  • Inhibitions
  • Tension

Associated Co-morbidities

Co-morbodities associated with alcoholism are usually psychological in nature. The following table shows the prevalance of different psychological disorders than have gone along with alcoholism.

Co-morbidities.jpg

The odds ratio represents the increased chance that someone with alcohol abuse or dependence will have the co-morbid psychiatric disorder.[3] From looking at the table, a person with alcohol depencence is 3.6 times more likely to also have a mood disorder compared to a person without alcohol dependence.

Medications

There are currently only three medications that are approved for the treatment of alcoholism.[3] These medications have been shown to help individuals dependent on alcohol reduce their drinking, avoid relapse back to heavy drinking, and achieve and maintain abstinence. They are as follows:

  • Disulfram (Antabuse) is an alcohol-sensitizing drug that will not cure alcoholism or remove the craving, but will cause severe physical reactions flushing, vomiting, nausea) if alcohol is consumed
  • Naltrexone (ReVia) blocks the narcotic high and reduces the urge to drink
  • Acamprosate (Campral) is an anti-craving medication to help abstain from alcohol

Diagnostic Tests/Lab Tests/Lab Values

Alcoholism is diagnosed through several screening tools. There are several tools that can be used to asses an individuals history of alcohol use, including the Short Michigan Alcoholism Screening Test (SMAST), the CAGE quesitonnaire, and the Alcohol Use Disorders Identification Test (AUDIT).[2]

  • The SMAST is a 13 item questionnaire that can be completed within minutes by answering "yes" or "no." The test is self-administered. A score of 1-2 indicates no problem, a score of 3 indicates a borderline alcohol problem, and a score of 4 indicates an alcohol problem.
  • The CAGE questionnaire is a four question survey used to identify the potential for an alcoholic problem.
  • The AUDIT is designed as a brief, structured interview or self-report survey that can easily be incorporated into a general health interview, lifestyle questionnaire, or medical history.[2] It is 10 questions that are based on the amount and frequency of drinking, alcohol dependence, and problems caused by alcohol.

It is often dificult to screen for alcohol abuse because some signs & symptoms (falling, memory loss) which may be associated with aging or people may complain about digestive problems, pain or weakness but never reveal alcohol abuse. Denial is a hallmark sign.[6]

Lab tests that may also be done are as follows:[7]

  • toxicology screen - used to determine the type and approximate amount of legal or illegal substances in a persons body
  • complete blood count - measures the total number of red and white blood cells, hemoglobin, and hematocrit
  • folate tests - measures the amount of folic acid in the blood
  • liver function tests
  • serum magnesium - measures the amount of magnesium in the blood
  • total protein
  • uric acid - measures the amount of uric acid in the blood

Causes

Alcoholism is a gradual process that occurs over an extended period of time. Over time alcohol alters the balance of chemicals in the brain such as gamma-aminobutyric acid (GABA), glutamate, and dopamine.[6] GABA inhibits impulsiveness. Glutamate excites the nervous system. Alcohol increases the level of dopamine in the brain which is associated with the pleasurable aspect of drinking. Excessive alcohol use may increase or decrease the amount of these chemicals causing cravings. There are other factors that can contribute to addiction process, such as:[6]

  • Genetics - certain genes may cause a person to be more vunerable to alcoholism
  • Emotional state – high levels of stress, anxiety, or emotional pain; certain stress hormones may also be associated
  • Psychological factors – depression, low self-esteem, being around drinking
  • Social or cultural factors - the media/advertisments sometimes portray excessive drinking as OK

Systemic Involvement

Excessive alcohol use can cause or contribute to many medical conditions.[2] It is extremely toxic and harmful to tissues of the body. Alcohol has a vasodilatory and depressant effects, which may produce fatigue and mental depression or alter the individuals perception of pain or symptoms. The different systems that alcohol may affect are the gastrointestional, hepatic, cardiovascular, hematopoietic, and neuromuscular systems.

  • Prolonged use of excessive alcohol may affect the metabolism, resulting in reduced bone formation, disruption of hte balance between bone formaiton and resorption, and incomplete mineralization.[2] They are also malnourished, which increases the effects alcohol has on bones.
  • Alcohol affects the central nervous system as a depressant.[7]
Liver cirrhosis.gif
  • The liver breaks down alcohol so it can be eliminated. If more alcohol is consumed than can be processed, the imbalance injures the liver by interfering with the normal breakdown of proteins, fats, and carbohydrates.[8] There are three types of liver disease which are related to alcohol consumptioin. The first is fatty liver, which is marked by a build up of fat cells. It will improve when the individual stops drinking. The second is alcoholic hepatitis, which is an inflammation of the liver. The damage may be reversible if drinking is stopped, but in its most severe form may be life threatening. The third is alcoholic cirrhosis (pictured below) and the most serious. Cirrhosis refers to the replacement of normal liver cells with scar tissue. The damage cannot be reversed and is life threatening.


  • The kidneys play a role in fluid regulation of the body as well as the production of hormones that regulates blood pressure, red cell prodection, and calcium metabolism. Alcohol directly effects kidney function by altering the form and structure of the organs.[9] The basement of the glomerulus becomes abnormally thick and is caused by cell proliferation. Further changes include enlarged and altered cells in tubules. The kidney may also swell.
Alcoholheart.gif
  • The heart is an important organ. Heavy consumption, over time, can lead to high blood pressure, alcoholic cardiomyopathy (enlarged and weakened heart - seen in the picture below), congestive heart failure, as well as stroke.[10] Drinking also puts more fat into circulation raising the triglyceride levels.
  • The pancreas serves two major functions - production of insulin and glucagon and the secretion of enzymes that aid in digestion.[11]  Alcohol consumption can cause pancreatitis, an inflammation of the pancreas, that can cause problems with digestion.

Medical Management (current best evidence)

Substance abuse of any kind requires an overall treatment program, including education, counseling, behavior modification, and for some substances, pharmacologic help.[4] Success depends on the individuals willingness to correct the problem and compliance with the treatment regimens. Alcoholics enter treatment reluctantly because they deny they have a problem. Types of treatment depend on level of dependence – may include evaluation, a brief intervention, an outpatient program or counseling, or an inpatient facility. Residential treatment programs include:[6]

  • Detoxification & withdrawal – detox (4-7 days), may experience delirium tremens or other withdrawal seizures
  • Medical assessment & treatment – high blood pressure, elevated blood sugar, and liver and heart disease are common medical problems
  • Psychological support & psychiatric treatment – counseling regarding the psychological aspects of alcoholism, family/couples therapy
  • Emphasis on acceptance & abstinence – need to accept the addiction for successful recovery
  • Drug treatments – see under medications section
  • Continuing support – help abstain from drinking, manage relapses, and cope with necessary lifestyle changes


Twelve Step Programs

Cognitive Behavioral Therapy

Motivational Interviewing

Physical Therapy Management (current best evidence)

Substance Abuse: Preferred Practice Patterns:[4]

  • 4A: Primary Prevention/Risk Reduction for Skeletal Demineralization (alcohol and tobacco use/abuse)
  • 5G: Impaired Motor Function and Sensory Integrity Associated with Acute or Chronic Polyneuropathies (alcohol-related)
  • 6G:Primary Prevention/Risk Reduction for Cardiopulmonary Disorders (all substances but especially cocaine and tobacco projects)
  • 6B:Impaired Aerobic Capacity and Endurance Secondary to Deconditioning Associated with Systemic Disorders (all substances but especially tobacco projects)
  • 7A:Primary Prevention/Risk Reduction for Integumentary Disorders (injection, drug use, tobacco use, and delayed wound healing, SCI population)

Subatance abuse, including alcoholism, can impair or slow the rehabilitation process, especially delay wound healing. The individual should be encouraged to reduce or eliminate if possible the intake, during the rehabilitation process to accelerate the healing process. Many people who seek medical attention fail to disclose their alcohol or drug use. Physical therapists must be alert to alcohol and other drug use and abuse. Since physical therapists generally spend more time with patients/clients than many other health professionals, they may be the ones best able to recognize substance abuse that would be hidden from those who spend less time with the client or who do not have the skills to recognize impairments of the cognitive and motor systems.[4] It may be helpful to assess the behavioral impact by asking the following questions:

  • When is it that you feel you need these substances?
  • How do these activities help you?
  • Are you concerned about your dependence?
  • Do you have a pattern of cutting back or stopping the use of alcohol, but then restarting it?
  • Have you been concerned or has anyone around you raised concern about your use of alcohol?

If an individual reports the use of alcohol, the therapist should ask whether the person has discussed it with their physician or other health care personnel. The individual should be encouraged to seek medical attention or that it will be addressed as part of the medical problem with the physician.

Differential Diagnosis

To diagnose alcohol abuse, the physician must rule out medical problems that cause symptoms similar to that of intoxicitation and withdrawl.[12]

  • Brain Trauma
  • Hypoglycemia
  • Electrolyte Imbalance
  • Diabetic Acidosis and Ketoacidosis
  • Meningitis
  • Neurological Conditions (Multiple Sclerosis)
  • Pneumonia
  • Stroke

Anyone of these conditions may cause an individual to be disoriented, unable to hold a conversation, has a short attention span, or have trouble walking or maintaining balance. One should also rule out depression and anxiety disorders.

Case Reports

The Impaired Patient: Ethics & Risks

Autonomy versus the Automobile

Resources

Alcoholics Anonymous
National Association for Children of Alcoholics Al-Anon/Alateen National Institute on Alcohol Abuse and Alcoholism National Council on Alcoholism and Drug Dependence

SASHMA

Recent Related Research (from Pubmed)

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References

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  1. World Book Encyclopedia. Alcoholism. 2001 Edition. pg. 337-338
  2. 2.0 2.1 2.2 2.3 2.4 Goodman, C. and Snyder T. Differential Diagnosis for Physical Therapist: Screening for Referral. 4th edition. St. Louis, Missouri:Saunders Elsevier
  3. 3.0 3.1 3.2 3.3 3.4 National Institute of Alcohol Abuse and Alcoholism. FAQ for the General Public. Retrieved March 30, 2010, from www.niaaa.nih.gov/FAQs/General-English/default.htm
  4. 4.0 4.1 4.2 4.3 Fuller, K. and Goodman, C. Pathology: Implications for the Physical Therapist. St. Louis, Missouri: Saunders Elsevier
  5. Buddy T. (2009, November 25) Signs and Symptoms of Alcoholism. Retrieved March 30, 2010 from http://alcoholism.about.com/od/about/a/symptoms.htm
  6. 6.0 6.1 6.2 6.3 6.4 Mayo Clinic Staff (2008, May 8) Alcoholism. Retrieved March 30, 2010 from http://www.mayoclinic.com/health/alcoholism/DS00340
  7. 7.0 7.1 7.2 7.3 Van Voorhees, B. (2010, March 23) Alcoholism. Retrieved March 30, 2010 from http://www.nlm.nih.gov/medlineplus/ency/article/000944.htm
  8. Liver Foundation. (2007, September 28) Alcohol-Induced Liver Disease. Retrieved March 30, 2010 from http://www.liverfoundation.org/education/info/alcohol/
  9. Epstein, M. (1997) Alcohol's Impact on Kidney Function. Alcohol Health & Research World, 21(1), 84-93. Retrieved March 30, 2010 from Proquest database
  10. Women's Heart Foundation (2007) Alcohol and Heart Disease. Retrieved March 30, 2010 from http://www.womensheart.org/content/HeartDisease/alcohol_and_heart_disease.asp
  11. Apte, M., Korsten, M. and Wilson, J. (1997) Alcohol-Related Pancreatic Damage: Mechanisms and Treatment. Alcohol Health & Research World, 21(1), 13-20. Retrieved March 30, 2010 from Proquest database
  12. Emmite, D. and Swierzewski, S. (2001) Alcohol Abuse: Differential Diagnosis. Retrieved March 30, 2010 from http://www.mentalhealthchannel.net/alcohol/differential-diagnosis.shtml