The alcohol in alcoholic beverages (ethyl alcohol) is produced by the fermentation of sugar. Ethyl alcohol is a potent central nervous system (CNS) depressant, and ingestion results in behavioral, mood, and physiologic changes. Although the effects of alcohol are proportional to the amount ingested, the destabilization of alcohol and the CNS effects of alcohol differ between people. When alcohol is ingested, about 20% is quickly absorbed through the stomach wall into the bloodstream, and 80% is absorbed more slowly into the bloodstream from the upper digestive tract. When a low dose of alcohol is ingested it produces a lessening of inhibition, sleepiness, relaxation, slurred speech, and loss of coordination. In high doses it may produce profound CNS depression with coma, respiratory arrest, and organ failure.

According to the Centers for Disease Control and Prevention, alcohol abuse is considered the number three cause of preventable death in the United States. Eighteen million Americans have alcohol use disorders but only 7% (per year) receive any treatment. The annual costs of alcohol-related problems in the United States are estimated at $185 billion.

The interplay of numerous biological, psychological, and sociocultural factors appear to be involved in alcohol-related disorders. The human genome is being studied in attempt to identify and define genetic risk factors and understand their interaction with environmental factors. Indeed, a child of one parent with alcohol-related disorder is seven to eight times more likely to become an alcoholic than a child without such a parent. Biological factors may include genetic or biochemical abnormalities, nutritional deficiencies, endocrine imbalances, and allergic responses.

Alcohol is the leading cause of death in children younger than age 21. In college-age students, nearly 600,000 are injured annually when under the influence of alcohol, and alcohol abuse is implicated in nearly 100,000 sexual assaults or date rapes. Across the lifespan, alcohol is commonly implicated in both nonfatal and fatal accidents. Children who begin drinking alcohol before age 15 are four times as likely to develop alcohol dependence even if their parents had no parental history of alcohol dependence.

Psychological factors may include self-medicating with alcohol to reduce anxiety or symptoms of mental illness; the desire to avoid responsibility in familial, social, and work relationships; and the need to bolster self-esteem. Alcohol-related disorders are common among individuals who also abuse other drugs. Individuals who are addicted to nicotine and who abuse alcohol aren’t as successful at quitting smoking and suffer higher rates of smoking-related illnesses. Further, it’s estimated that 90% of people who suffer from cocaine addiction also have alcohol-related disorders.

Sociocultural factors include the availability of alcoholic beverages, group or peer pressure, an excessively stressful lifestyle, and social and familial attitudes that approve of frequent drinking. Research has shown that nearly 80% of adolescents near the end of high school begin to drink. And, nearly 9% of 6th grade students surveyed had consumed a beer in the previous year.

Alcohol-related disorders cuts across all social and economic groups, involves both sexes, and occurs at all stages of the life cycle, beginning as early as elementary school. The focus of research on the cause and treatment of alcohol-related disorders requires a lifespan perspective.

Because alcohol-related disorders occur across the lifespan, agespecific and sensitive diagnostic assessment tools must be used.

The patient with alcohol dependence may hide or deny his addiction and may temporarily manage to maintain a functional life. Assessing for abuse or dependence can be difficult. Look for these physical and psychosocial symptoms that suggest alcohol-related disorders:

• need for daily or episodic alcohol use to maintain adequate functioning

• inability to discontinue or reduce alcohol intake

• episodes of anesthesia or amnesia (blackouts) during intoxication

• episodes of violence during intoxication

• interference with social and familial relationships

• interference with school or occupational responsibilities

• intake during pregnancy

• malaise, dyspepsia, mood swings, depression, and an increased incidence of infection

• poor personal hygiene

• unexplained injuries, such as burns, fractures, and bruises

• unusually high tolerance of sedatives and opioids

• memory or cognitive impairment (at any age)

• legal problems associated with driving under the influence, property or violent crime, or sexual assault

• abuse of other substances such as cocaine

• mood, anxiety, or personality disorders

• child with fetal alcohol spectrum disorder (FASD)

• multiple minor complaints.

Although each person abusing alcohol may present in a unique way, secretive or manipulative behavior may be a manifestation of the patient’s denial of the severity of his addiction. Proactive screening may be necessary to identify alcohol-related disorders in young adult patients because they rarely identify themselves as having alcohol abuse problems. Suspect alcohol-related disorder if the patient uses inordinate amounts of aftershave or mouthwash. When confronted, the patient may deny or rationalize the problem. Or, he may be guarded or hostile in his response and may even sign out of the hospital against medical advice. He also may project his anger or feelings of guilt or inadequacy onto others to avoid confronting his illness. The blood alcohol level in a physically dependent and tolerant drinker may exceed levels that would cause severe dysfunction or death in a nontolerant drinker. For example, a tolerant drinker might have a blood alcohol level of more than 0.5 mg (the usual lethal level) and still be alive, talking, and moving.

After abstinence or reduction of alcohol intake, signs and symptoms of withdrawal—which begin shortly after drinking has stopped and last for 5 to 7 days—may vary. (See Signs and symptoms of alcohol withdrawal, page 6.)

The patient initially experiences:

• anorexia, nausea, and diaphoresis

• anxiety with tremor that progresses to severe tremulousness and agitation; possibly hallucinations and violent behavior

• insomnia

• major motor seizures (alcohol withdrawal seizures) during withdrawal.

Suspect alcohol-related disorder in any patient with unexplained seizures.

Chronic alcohol abuse is implicated in many physical and psychological complications, including:

• malnutrition

• aggravation of chronic diseases such as hypertension, stroke, and memory loss

• alcoholic liver diseases

• neurotoxicities and brain damage

• cardiac diseases

• immune system changes resulting in diminished disease resistance

• oropharyngeal and GI cancers

• fetal alcohol syndrome

• endocrine system changes (Prenatal alcohol exposure causes changes in the pituitary, adrenal, and hypothalamus glands that result in persistently elevated levels of stress hormones.)

• mood, personality, anxiety, and sleep disorders

• prescription drug interactions that may result in harmful side effects or diminished medication benefit.

Assess for these complications in a patient with suspected alcohol-related disorder. (See Complications of alcohol use, page 8.)

For characteristic findings in patients with alcoholism, see Diagnosing substance dependence and related disorders, page 9.

In addition to client and family assessment, clinical findings may help support the diagnosis of alcohol-related disorder. For example:

• Laboratory tests confirm alcohol use and document recent alcohol ingestion. A blood alcohol level ranging from 0.08% to 0.10% weight/volume (200 mg/dl) is accepted as the level of intoxication, depending on the state or country.

• Blood urea nitrogen level is increased, serum ammonia level is increased, and serum glucose level is decreased in liver disease.

• Liver function studies consistent with liver damage reveal increased levels of serum cholesterol, lactate dehydrogenase, alanine aminotransferase, aspartate aminotransferase, and creatine phosphokinase.

• Elevated serum amylase and lipase levels are consistent with pancreatitis.

• Urine toxicology may reveal other drug use.

• Hematologic studies identify anemia, thrombocytopenia, increased prothrombin time, and increased partial thromboplastin time.

• Liver ultrasound studies can reveal hepatomegaly.

• Cardiac echocardiography may show cardiomyopathy.

• Diagnosis of alcohol-related disorder is confirmed when Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision criteria are met.

Researchers are attempting to develop biomarkers to help identify patients with chronic alcohol abuse, alcohol-related tissue injury, and FASD. Current research seeks to identify the pharmacodynamic effects of alcohol, the quantification of and changes in neurotransmitters, and the effects of genetic expression and environmental factors on an individual’s potential to develop alcohol-related disorders. In the future, imaging technologies, such as diffusion tensor magnetic resonance imaging, may be useful for identifying
alcohol-induced brain tissue changes.

Total abstinence from alcohol is the only effective treatment. Supportive programs that offer detoxification, rehabilitation, and aftercare, including continued involvement in Alcoholics Anonymous (AA), may produce good long-term results. For long-term success, the recovering individual must learn to fill the place alcohol once occupied in his life with something constructive.

Supportive counseling or individual, group, or family psychotherapy
may help. Ongoing support groups are helpful. In AA, a self-help group with more than 2 million members worldwide, the alcoholic finds emotional support from others with similar problems. About 40% of AA’s members stay sober as long as 5 years, and 30% stay sober longer than 5 years.

Acute intoxication is treated symptomatically by:

• supporting respiration

• preventing aspiration of vomitus

• replacing fluids and giving I.V. glucose to prevent hypoglycemia

• correcting hypothermia or acidosis

• monitoring for seizure activity or withdrawal

• starting emergency treatment for trauma, infection, or GI bleeding.

Treatment of chronic alcohol abuse requires a varied approach that may include:

• drugs to deter alcohol use and treat effects of withdrawal

• psychotherapy, consisting of behavior modification techniques, group therapy, and family therapy

• appropriate measures to relieve associated physical problems and psychiatric disorders.