Alcohol use disorders

Introduction

Encompasses alcohol abuse and dependence
More community harm occurs from acute health and social effects of alcohol use than long-term alcohol dependence
Upwards of 30% of ED visits are alcohol-related

DSM-V definition of alcohol use disorder

Alcohol often taken in larger amounts or over a longer period than intended
Persistent desire or unsuccessful efforts to cut down or control use
Great deal of time spent in activities necessary to obtain alcohol, use alcohol or recover from it
Craving or a strong desire or urge to use alcohol occurs
Recurrent alcohol use results in failure to fulfill major role obligations at work, school or home
Alcohol continues despite persistent or recurrent social or interpersonal problems caused by or exacerbated by the effects of alcohol
Important social, occupational or recreational activities are given up or reduced because of alcohol use
Recurrent use occurs in situations in which it is physically hazardous
Continued use despite knowledge of physical or psychological problem caused or exacerbated by alcohol

Tolerance occurs as defined by either of:
- A need for markedly increased amounts of alcohol to achieve intoxication or desired effect
- A markedly diminished effect with continued use of the same amount of alcohol
Withdrawal occurs as manifested by either of:
- Characteristic withdrawal syndrome
- Alcohol (or benzo) taken to relieve or avoid withdrawal symptoms
At least 2 of above constitutes an alcohol use disorder
Mild: 2 or 3 criteria
Moderate: 4 or 5 criteria
Severe: 6 or more criteria

Tools

AUDIT identifies patients with at-risk, hazardous or harmful drinking
- Sensitivity 51-97%
- Specificity 78-96%
CAGE identifies alcohol abuse and dependence
- Sensitivity 43-94%
- Specificity 70-97%
Single question ‘On a typical day when you are drinking, how many drinks do you have?’ to trauma patients correlates well with AUDIT score
Early detection allows brief intervention strategy e.g. FRAMES, which has been shown to decrease alcohol consumption in non-dependent patients

CAGE

FRAMES

Feedback: Review problems caused by alcohol with the patient
Responsibility: Point out that changing behaviour is the patients responsibility
Advice: Advise patient to cut down or abstain
Menu: Provide options to assist patient to change behaviour
Empathy: Use empathic approach
Self-efficacy: Encourage optimism that the patient can change behaviour

Alcohol withdrawal

Develops within 6-24 hours of cessation or reduction in alcohol consumption in dependent individuals
Peaks at 72 hours
Diminishes by days 5-7
Common in patients admitted to hospital
Down-regulation of neuro-inhibitory GABA receptors leads to symptoms of GABA excess in withdrawal
Alcohol also inhibits the excitatory NMDA glutamate receptor and withdrawal removes this inhibition
Increased DA and NA neurotransmission also occurs

Alcohol withdrawal

Autonomic excitation
- Occurs within hours and peaks at 24-48 hours
- Tremor, anxiety, agitation, sweating, tachycardia, HTN, nausea, vomiting, hyperthermia
Neuro-excitation
- Occurs within 12-48 hours
- Hyperreflexia, nightmares, hallucinations (visual, tactile +- auditory), generalised tonic-clonic seizures
Delirium tremens
- Severe form with mortality near 8%
- Up to 20% of patients admitted with alcohol withdrawal in urban centres
- Hallucinations, delirium, global confusion, sympathetic hyperactivity, respiratory and cardiovascular collapse and death
- Usually from days 3-12

Comorbidities

Wernicke’s encephalopathy

Triad of: Ataxia, confusion and opthalmoplegia (horizontal nystagmus)
- + Reduced LOC, coma, unexplained hypotesion, hypothermia
- Reversible
Korsakoff psychosis
- Progressive mental impairment characterised by short-term memory loss and confabulation
- Chronic and irreversible

Management of withdrawal

Mild – Symptomatic diazepam over 2-7 days as outpatient
- Relapse common if inadequate psychosocial support
Inpatient detox more suitable if:
- Previous severe withdrawal
- Poor social support
- Failure of unsupervised outpatient withdrawal
- Presenting in severe alcohol withdrawal
- Significant psychiatric comorbidities
- Significant medical complications or comorbidities

Delirium tremens
- Resus
- Diazepam 5-10mg IV q15min until resolution of symptoms/seizures
  - Phenytoin not indicated in alcohol withdrawal seizures
- Detect and treat hypoglycaemia
- AWS with regular diazepam 5-20mg PO
- Thiamine 200mg IV TDS for first 24 hours and continued for 3 days if altered mental status and higher dose if Wernicke’s
- Monitor fluid balance, electrolytes
- Detect and treat comorbidities
Suspected Wernicke encephalopathy
- Thiamine 100mg IM or IV TDS for 3-5 days then 100mg TDS PO
Probable Wernicke encephalopathy
- Thiamine 300mg IM or IV TDS for 3-5 days then 100mg TDS PO
- OR Pabrinex *
- High-dose Vitamin C supplementation
- High-dose B vitamin supplementation
*Pabrinex
- Ampoule 1 – B1, B2 and B6
- Ampoule 2 – Vitamin C, nicotinamide, glucose

Stages of withdrawal

I – 6-24 hours
- Anxiety, restless, inattention, tremulous, insomnia, craving
II – 24
- Hallucinations, misperceptions, irritability, confused, hypervigilant
III – 48 hours
- Generalised seizures
IV – >48 hours
- Confusion, autonomic hyperreactivity, tremors, hallucinations, seizures, hyperadrenergic

Management of withdrawal

Mild (AWS 6-10)
- Diazepam 5-10mg QID for first 48 hours
- Possibly as outpatient
Moderate to severe (AWS 11-25)
- Diazepam 10-20mg q1-2hrly until AWS <10 then 5-10mg QID for 48 hours
- Obtain specialist advice once 120mg provided
- May be managed in short stay
Severe (AWS 25)
- Slow injection IV diazepam 5mg repeated up to 4 times in first 30 minutes
- Diazepam 5mg q30min PRN
- After 24 hours – 10-20mg QID dose reduced over 3-5 days

Last Updated on August 28, 2023 by Andrew Crofton

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