Alcohol use disorder is very common in the United States. The cause of alcohol use disorder is not well understood, however, several factors are thought to contribute to its development. These include the home environment, peer interactions, genetic factors, level of cognitive functioning, and certain existing personality disorders. This activity reviews the evaluation and management of alcohol use disorder and highlights the role of the interprofessional team in the recognition and management of this condition.
Identify the etiology of alcohol use disorder.
Describe various presentations of alcohol use disorder.
List the treatment options available for alcohol use disorder.
Explain interprofessional team strategies for improving care coordination and communication to improve outcomes in patients with alcohol use disorder.
Alcohol misuse has been linked to numerous social, economic, and health problems. Estimates vary but have suggested that up to 40% of patients have experienced complications of alcohol misuse. In the United States, 138.3 million people age 12 and older, surveyed, report that they actively use alcohol, according to the 2015 National Survey on Drug Use and Health. Of those, 48.2% report that they had binge drinking episode(s) within 30 days before taking the survey. Of those who reported binge drinking, 26% reported heavy alcohol use, defined as binge drinking five or more days in the previous 30 days, which accounts for 12.5% of total alcohol users. This means that 5.9%, or 15.7 million people in the United States aged 12 and older, meet criteria for an alcohol use disorder (see image for criteria). More than 85,000 deaths per year can be attributed to alcohol.
In addition, motor vehicle accidents, dementia, depression, homicide and suicide have all been linked to alcohol use disorder.
Although the pathogenesis of alcohol use disorder is not strictly known, several factors are thought to contribute to its development. These include environmental influences, such as home environments, peer interactions, genetic factors, the level of cognitive functioning, and certain existing personality disorders. Some of the genes suspected include GABRG2 and GABRA2, COMT Val 158Met, DRD2 Taq1A, and KIAA0040. Personality disorders associated with the development of an alcohol use disorder include disinhibition and impulsivity-type disorders, as well as depressive and socialization-related disorders.
According to the 2015 National Survey on Drug Use and Health conducted by the Substance Abuse and Mental Health Administration, an estimated 20.8 million Americans age 12 and older had a substance use disorder, of which 15.7 million were alcohol use disorders. Of those, 2.7 million had an illicit drug use disorder as well. This number makes alcohol the leading substance abused in the United States. Of the people with alcohol use disorder and illicit drug disorder, 623,000 of these were adolescents ages 12 to 17 (2.5% of all adolescents). Almost four million (3.8 million) individuals ages 18-25 (10.9% of young adults) and 11.3 million individuals 26 years or older (5.4%) had both an alcohol use disorder and illicit drug disorder. However, this number has been steadily declining since 2002. Almost half of the people with any substance abuse problem, including alcohol, also had a co-existing mental illness.
Overall alcohol use disorder tends to be more common in individuals with less education and low income.
Globally, alcohol use disorder affects 240 million people mostly in Europe and the Americas.
Multiple theories have been suggested as to why some people develop alcohol use disorders. Some of the more evidence-supported theories include positive-effect regulation, negative-effect regulation, pharmacological vulnerability, and deviance proneness. Positive-effect regulation results in drinking for positive rewards (such as feelings of euphoria). Negative-effect regulation is seen when one drinks to cope with feelings of a negative nature, such as depression, anxiety, or feelings of worthlessness. Pharmacological vulnerability makes a note of an individual's varied response to both acute and chronic effects of alcohol intake and the individual differences in the body's ability to metabolize the alcohol. Deviance proneness speaks more to an individual's tendency towards deviant behavior established during their childhood, often due to a deficiency in socialization at an early age.
The metabolism of alcohol is affected by many factors. Females tend to eliminate alcohol faster than men, although their first-pass metabolism is slower due to lower antidiuretic hormone (ADH) levels, resulting in higher blood alcohol concentration initially. Fetal livers also eliminate alcohol more slowly due to CYP2E1 and ADH not being fully expressed. Native Americans eliminate alcohol more quickly as well, due to the expression of beta-3 Class 1 ADH isoforms as opposed to subjects only expressing the beta-1 isoform. Alcohol metabolism is also lower in a fasting state, as when one is fed. This is due to the lower ADH levels seen in the fasting state. There is also an impact on alcohol elimination seen with a time of day; the highest elimination is seen at the end of the daily dark period. Heavy drinking also increases the rate of elimination, although this does eventually slow, once the advanced liver disease is present. Medications that act as ADH inhibitors will slow the alcohol elimination rate. H2 receptor blockers will also inhibit ADH, thereby reducing the first-pass metabolism in the stomach and increasing blood alcohol levels.
History and Physical
History gathering will often reveal reported episodes of binge drinking of four or five or more drinks at a time. Use of the CAGE questionnaire will reveal a score of 2 or greater (CAGE means (1) have you ever felt you should Cut down on your drinking, (2) have you ever been Annoyed by people criticizing your drinking, (3) have you ever felt Guilty about your alcohol use, or (4) have you ever needed an Eye-opener to steady your nerves or get rid of a hangover). The patient may also report frequent falls, blackout spells, unsteadiness, or visual disturbances. They may report seizures if they went a few days without drinking, or tremors, confusion, emotional disturbances, and frequent job changes. They may also report social issues, such as job termination, separation/divorce, estrangement from family, or loss of their home. They may also report sleep disturbances.
The patient may have hypertension (HTN) or insomnia initially. In later stages, the patient may complain of nausea/vomiting, hematemesis, abdominal distension, epigastric pain, weight loss, jaundice, or other symptoms or signs suggestive of liver dysfunction. They may be asymptomatic early on.
To screen for alcohol use disorder the following tools are recommended by the US Preventive Services Task Force:
Abbreviated 3 question Audit test
The 10 question alcohol use disorders identification test (AUDIT)
Single question screening
On exam, they may exhibit signs of cerebellar dysfunction, such as ataxia or difficulty with fine motor skills. They may exhibit slurred speech, tachycardia, memory impairment, nystagmus, disinhibited behavior, or hypotension. They may present with tremors, confusion/mental status changes, asterixis, ruddy palms, jaundice, ascites, or other signs of advanced liver disease. There may also be spider angiomata, hepatomegaly/splenomegaly (early; liver becomes cirrhotic and shrunken in advanced disease). They may develop bleeding disorders, anemia, gastritis/ulcers, or pancreatitis as complications of alcohol use. Labs will reveal anemia, thrombocytopenia, coagulopathy, hyponatremia, hyperammonemia, elevated ammonia levels, or decreased B12/folate levels as the advanced liver disease develops.
Evaluation should include questions about alcohol use, specifically how often and how much. A CAGE questionnaire as described above should be used, as well as the screening questions for alcohol use disorder that are displayed in the image below. The practitioner should elicit a family history regarding alcohol and other substance use disorders, as well as a family and personal history of any psychiatric disorders. The patient should be screened for any medical or behavioral complications of alcohol abuse, such as macrocytic anemia, elevated liver enzymes, coagulopathies, pancreatitis, frequent falls, job loss, relationship issues, or aberrant behaviors such as risky sexual behavior or impulsiveness.
Use of alcohol biomarkers:
Indirect: AST, ALT, GGT, MCV, CDT
Direct: Levels of alcohol and ethyl glucuronide
Treatment / Management
Some treatment foci that have demonstrated promise include evidence-based motivational interviewing. This particular approach helps the patients explore the reasons behind their ambivalence with respect to changing their behavior or alcohol cessation to change their substance abuse-related behaviors with a personalized assessment of risks and needs. Other therapies include cognitive behavior therapy, 24-hour residential facilities that aim to treat medical as well as psychiatric complications or comorbidities associated with the alcohol use and process of cessation. There are also multiple programs, such as Alcoholics Anonymous or other 12-step programs that focus on group support/mentors that can provide a source of assistance with the maintenance of abstinence. Many patients have lapses during their lifetime and will require initiation of differing intensities of therapy throughout their lifetime.
Clinician advice on harms of alcohol makes a big difference
Hospitalize patients with delirium tremens. Patients with no social support, major psychiatric disorders, and history of relapse should be admitted
Urge patient to remove all alcohol from the home
Encourage family members to attend AA
Both naltrexone and acamprosate can be used to treat alcohol abuse disorder when non-pharmacological methods do not work
Disulfiram is no longer recommended
Second line drugs of choice include gabapentin and topiramate
Alcohol use disorder is not a benign disorder. Based on WHO reports, it is associated with at least 3 million deaths each year, most of these occurring in men. Besides death, alcohol use disorder is associated with:
Esophageal, liver and breast cancer
Homicide and suicide
Deterrence and Patient Education
Alcoholics tend to have poor dietary choices, and folate deficiency is common
Encourage a healthy diet of fruits and vegetables
Pearls and Other Issues
Complications of alcohol use disorders can be far-reaching and can impact a patient's socioeconomic status, mental health, interpersonal relationships, employment, and physical well-being.
Early intervention and repeated non-malignant discussions between the patient and provider are important.
The patient's successes should be noted and resources for continued efforts offered at each visit.
Discussion regarding barriers to the patient seeking cessation or assistance should occur to find new ways to approach the alcohol use disorder (AUD) in the hope of improving successful cessation of the behaviors.
Enhancing Healthcare Team Outcomes
Alcohol use disorder is very common in the US. Unfortunately, most people never come to medical attention until they have a medical problem or get involved with the legal system. The repercussions of alcohol use disorder go way beyond just addiction; the disorder can create havoc in the lives of the family, friends and lead to difficulties in interpersonal and professional relationships. Alcoholics never seek help on their own. The majority of alcoholics never come to medical attention because clinicians never screen them for alcohol use disorder. With an epidemic on the rise, there is now a national agenda to curb alcohol use disorder. All healthcare workers have a responsibility to watch out for alcoholics and make appropriate referrals.
Primary care workers, nurse practitioners, and pharmacists should educate patients about the harms of alcohol. In-patients should be offered counseling if they are deemed to be alcoholics. Because many of these alcoholics also have psychiatric issues, a mental health nurse should follow them as outpatients and make appropriate recommendations.
Clinicians should urge patients to attend AA and take their family members with them. If this fails, then clinicians may have to try pharmacological therapies. At the same time, cognitive behavior therapy should be offered. An interprofessional team approach should be adopted so that no alcoholic is missed; the key is to educate patients at every opportunity. Alcohol use disorder has no therapeutic benefits and it creates havoc in families.
The prognosis for most alcoholics is guarded; with less than 20-30% discontinuing drinking. Unfortunately, in many instances, some of the organ damage is often irreversible. The key is to educate the patient and the family about the destruction that alcohol can cause. Referral to alcoholics anonymous is recommended, but data indicate that compliance is often low. (Level V)
(Click Image to Enlarge)
DSM V criteria for alcohol use disorder
Contributed by Sara M Nehring
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