Alcohol use disorder
Alerts and Notices
Synopsis
Patients suffering from alcohol use disorder commonly present for medical evaluation, and many require emergent care and/or stabilization. The need for emergent care extends across the entire spectrum of alcohol use disorder, including patients seeking help and preventive care, acute management of alcohol intoxication, complications of acute intoxication (eg, trauma, severe electrolyte derangements, alcoholic / starvation ketoacidosis), and alcohol withdrawal syndrome.
Diagnosis Overview:
Alcohol use disorder is a pattern of alcohol use leading to clinically significant impairment or distress, as manifested by multiple psychosocial, behavioral, or physiologic features. Formerly viewed as two distinct disorders, alcohol abuse and alcohol dependence, alcohol use disorder is now viewed as a single disorder, categorized as mild, moderate, or severe. In the United States, up to 29% of people meet the criteria for an alcohol use disorder in their lifetime. Risk factors include younger age, male sex, Native American race, and having a disability, mood disorder, or other substance use disorder. Genetic factors are also implicated in alcohol use disorder.
Patients present with a range of clinical findings that include dysarthria, gastrointestinal symptoms (ie, nausea, vomiting, abdominal pain), tachycardia, hypertension, sleep disturbance, hypoglycemia, nystagmus, tremor, memory impairment, and headache. Behavioral and psychosocial findings include cravings; difficulty quitting; interference with relationships and maintaining job, school, and home responsibilities; and incidences of risky behavior that may harm others or cause self-harm. Associated diagnoses include liver cirrhosis, depressive disorder, gastritis, gastrointestinal tract bleeding, difficult-to-control diabetes, erectile dysfunction, Wernicke-Korsakoff syndrome, cardiomyopathy, seizures, and acute pancreatitis. Pregnant individuals face a greater risk of miscarriage and birth disorders due to fetal alcohol syndrome. Severe intoxication with high levels of blood alcohol, or alcohol toxicity, is life-threatening and requires immediate medical attention.
Management is multifaceted and includes physiologic support, detoxification, residential rehabilitation treatment, cessation and withdrawal support, lifestyle changes, medications (eg, disulfiram, naltrexone, acamprosate), cognitive behavioral therapy, individual and group therapy, family therapy, and support programs.
Patients with this disorder may have an increased risk of various general medical conditions.
Cardiovascular effects: Acute and chronic alcohol consumption can have acute and chronic implications to the cardiovascular system. These include mechanical disturbances of the heart (eg, dilated cardiomyopathy) that produce dysrhythmias and exacerbation of coronary artery disease. In the emergent care setting, providers must be aware of signs of symptoms of heart failure (see alcoholic cardiomyopathy) as well as possible dysrhythmias, including supraventricular dysrhythmias (usually atrial fibrillation) and ventricular dysrhythmias (ie, transient ventricular tachycardia). Collectively, dysrhythmias can result in "holiday heart" due to heavy alcohol consumption. Acutely, providers should perform a detailed history and physical to evaluate for the cardiovascular effects of alcohol use disorder. This may include alcohol levels, blood glucose levels, blood chemistries, troponin levels, ECGs, and chest radiography. Management of alcohol-related cardiovascular effects will depend on the severity of the derangement but not uncommonly will result in hospitalization.
Pulmonary and infectious disease effects: Consuming drinks that contain 10-20 grams of alcohol is linked to an 8% increased risk of developing community-acquired pneumonia, with disproportionately high rates of Klebsiella pneumoniae infection. For patients with unexplained hypoxia, respiratory distress, cough, or other cardiopulmonary complaints, providers should assess for pneumonia with lung auscultation and chest radiography.
Gastrointestinal effects: The gastrointestinal effects of alcohol are among the most profound, common, and potentially life-threatening. Patients with alcohol use disorder have a higher incidence of gastritis, esophagitis, gastrointestinal-related malignancies, pancreatitis, and malabsorption issues, with many irreversible problems such as liver damage and cirrhosis. Alcohol-related liver disease is well recognized as a primary finding in patients with alcohol use disorder, manifesting in ways such as asymptomatic liver dysfunction, portal hypertension, platelet disorders, ascites, and hepatocellular carcinoma. Complications from portal hypertension include esophageal varices, liver fibrosis (which is not reversible but can be halted with alcohol cessation), and even hepatic encephalopathy. Gastrointestinal bleeding is among the most acute, life-threatening manifestations of alcohol use disorder, which can be a result of Mallory-Weiss tears, bleeding esophageal varices, erosive gastritis / esophagitis, or even Boerhaave syndrome. Alcoholic hepatitis is yet another gastrointestinal manifestation that results in patients presenting acutely with a range of symptoms and clinical presentations, including upper abdominal pain, tender liver, fever, jaundice, and abnormal liver function studies, and can even present as fulminant liver failure. The model for end-stage liver disease (MELD) score can be used to predict mortality in alcoholic hepatitis but may not be useful in the emergency setting.
Patients with alcohol use disorder presenting with life-threatening manifestations very commonly get admitted to the hospital, especially when a diagnosis of cirrhosis is present that requires rapid emergent evaluation, care, and potentially stabilization. Providers must assess for the complications of alcohol use disorder, which commonly include laboratory values such as CBCs, complete metabolic panels including liver function studies (AST, ALT, PT-INR, PTT), lipase, ECGs, and ammonia and type and screen if bleeding is of concern. Gastrointestinal bleeding is among the most urgent and life-threatening manifestations of alcohol use disorder, and providers need to be prepared for rapid deterioration of a patient with gastrointestinal bleeding, including access to vitamin K and blood products, intravenous (IV) access for the patient, and emergent gastroenterology consultation.
Neurological effects: Acute alcohol ingestion lowers the seizure threshold. Neuropathy, Wernicke-Korsakoff syndrome, alcoholic cerebellar degeneration, and hepatic encephalopathy are among the most common and dangerous neurological manifestations of chronic alcohol use disorder. Neuropathy can manifest as symmetric sensorimotor polyneuropathy, usually located in the lower extremities due to the direct toxic effects of alcohol and vitamin B12 deficiency. Acute treatment for this may involve an electromyograph (EMG), IV or oral thiamine, and possibly even hospitalization.
Metabolic effects: People with alcohol use disorder frequently present acutely with symptomatic (or even asymptomatic) hypoglycemia; thus, intoxicated patients must have a blood glucose check done upon arrival. Hypoglycemia can cause seizures and further develop into alcoholic ketoacidosis, which is a common complication of alcohol use disorder that usually requires hospitalization. Alcoholic ketoacidosis is usually found after a patient binge drinks, followed by 1-3 days of nausea, vomiting, abstinence, and dehydration, and then the patient presents with abdominal pain, nausea, and vomiting. Blood pH may be normal or acidic, and electrolyte disturbances such as hypokalemia and hypomagnesemia may be present. All patients with alcohol use disorder who present with nausea and vomiting should receive a complete metabolic panel, and then receive thiamine and glucose. Lastly, patients with alcohol use disorder frequently have other metabolic derangements, such as hypocalcemia, hypomagnesemia, hypokalemia, hypophosphatemia, and hyponatremia. Hypomagnesemia is the most common electrolyte abnormality, and since most stores are intracellular, serum magnesium levels may be normal. Long-term treatment requires improved diet and nutrition and alcohol cessation.
Hematologic effects: Chronic alcohol use results in numerous hematologic effects, partly due to the toxic effects of alcohol and its metabolites, but also due to nutritional deficiencies, liver dysfunction, and bone marrow suppression. This can result in anemia, leukopenia, and thrombocytopenia. Megaloblastic anemia is common due to folate deficiency. Thus, it is reasonable to give thiamine and folic acid to all patients suffering from alcohol use disorder. Additionally, alcoholics frequently have chronic inflammatory diseases that result in anemia of chronic disease. Similarly, leukopenia is common, which can result in decreased inflammatory responses and poor recovery after illness.
Psychiatric effects: Alcohol use disorder and other substance use disorders are frequently associated with depression and antisocial personality disorder. Concurrent mental illness, including major depression and antisocial personality disorder, increase the risk for violence and suicidality. Treatment of concurrent mental illness is crucial for alcohol cessation.
Pregnancy effects: No safe level of alcohol consumption has been observed in pregnancy. Alcohol is a potent teratogen that can affect fetal growth and development at all stages of pregnancy. Additionally, alcohol freely passes through a lactating mother's milk; thus, mothers who consume alcohol should refrain from breastfeeding for up to 4 hours after moderate-to-high levels of alcohol consumption.
Trauma effects: Trauma is the leading cause of death in the United States for individuals between the ages of 1 and 44 years, and alcohol is a major risk factor for all types of traumatic injuries. Alcohol intoxication has several deleterious effects in the setting of trauma, including volume depletion, lower blood pressures, neurological suppression due to intoxication, cardiac depressant, and sensitivity to abdominal injuries due to liver dysfunction and splenomegaly. Additionally, people with chronic alcohol use disorder are at risk for acute and chronic subdural hematomas, epidural hematomas, concussions, spine fractures, and other long bone fractures. Intoxicated patients should be placed in a gown, and providers should perform a complete integumentary examination assessing for any signs of trauma. Intoxicated patients are a vulnerable population, and liberal use of radiography and CTs are warranted, especially if neurological changes or depression are present.
Codes
ICD10CM:F10.20 – Alcohol dependence, uncomplicated
SNOMEDCT:
7200002 – Alcoholism
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Last Reviewed:09/05/2022
Last Updated:04/03/2023
Last Updated:04/03/2023
Patient Information for Alcohol use disorder
Overview
Alcohol abuse and alcohol dependence were once considered separate diagnoses, but recently were renamed under one title: alcohol use disorder. Alcohol use disorder refers to the mental, physical, behavioral, and social effects of excessive alcohol consumption.Too much alcohol consumption contributes to heart, liver, lung, stomach, and pancreatic disease, as well as certain infections and cancers. Alcohol use disorder may be accompanied by depression, anxiety disorder, post-traumatic stress disorder (PTSD), eating disorders, sleep disturbances, or other substance use disorders.
Alcohol use disorder in pregnant individuals contributes to fetal alcohol syndrome (birth disorders). Alcohol abuse contributes to accidents and fatalities (including violent crimes, domestic abuse, and suicide).
Who’s At Risk
Younger adults, males, Native Americans, persons with severe disabilities, substance abusers, and individuals with mood disorders have higher rates of alcohol use disorder.The causes are complicated, but the likelihood of developing alcohol use disorder seems to be related to genetics (it runs in the family), personality traits (low impulse control, outgoing), and social environment (prenatal exposure to alcohol, and alcohol abuse among family, friends, or peers).
Signs & Symptoms
Alcohol use disorder ranges from mild to moderate to severe. Drinking too much can affect many of your body's systems.Brain:
Alcohol affects the way the brain works and can cause mood and behavior changes, difficulty thinking clearly, and lack of coordination.
Heart:
Drinking too much alcohol can damage the heart, causing irregular heartbeat, stroke, or high blood pressure.
Liver:
Heavy drinking causes liver inflammation, fatty liver, hepatitis, fibrosis, cirrhosis, and cancer.
Pancreas:
Alcohol causes the pancreas to produce toxic substances. In excess, this causes pancreatitis, a swelling of the blood vessels in the pancreas.
Immune System:
Drinking too much weakens the immune system. Chronic drinkers are more likely to contract diseases such as pneumonia and infections.
Signs of chronic alcohol use also include small broken blood vessels of the face (angiomata), reduction in testicles, erectile dysfunction, and enlarged breasts or spleen. Long term excessive alcohol use has been reported to increase your risk of certain cancers such as mouth, esophagus, pharynx, larynx, liver, and breast cancer.
Psychosocial symptoms include disruption of relationships, employment, and responsibilities, acting reckless, perpetual cycle of craving, intoxication, guilt, quitting, and self-loathing.
Excessive alcohol intake, alcohol toxicity, and binge drinking are life-threatening and can cause hallucinations, unconsciousness, coma, seizure, and death.
Self-Care Guidelines
Persons with alcohol use disorder may deny any alcohol abuse, or they may be aware of their alcohol cravings and of the adverse effects on their life, family, and work. The first step in recovery is to face the truth.Many people stop drinking successfully by committing to lifestyle changes, finding a support system (12-step program or other recovery program), seeking medical advice, and following a plan made in conjunction with a health care provider or recovery sponsor.
When to Seek Medical Care
If your health and well-being are impaired due to alcohol use disorder, seek help from your health care provider. When excessive alcohol consumption, binge drinking, or alcohol withdrawal causes severe or life-threatening illness, call an ambulance.Treatments
Your health care provider will give you a physical exam and ask questions related to your frequency of alcohol consumption and adverse effects you may be having. You may be referred to a residential treatment facility, addiction counselor, or other recovery program. Psychotherapy may include individual and/or group counseling and behavioral therapy. Medications may be prescribed to ease you through the side effects of withdrawal and maintaining sobriety.If you suffered alcohol toxicity, dehydration, and malnutrition, you may be treated with intravenous (IV) hydration and tube feeding. If your breathing is impaired, you may be put on breathing tubes to improve respiration. If needed, you may be treated for liver or cardiovascular disease, or referred to specialists.
Alcohol use disorder