Alcoholism and Addiction:
Medical Issues
Eric Lind Johnson, M.D.
Assistant Professor
Department of Family and Community
Medicine
UNDSMHS
Altru Health System
Objectives
• Review basic physiology, signs, and
symptoms related to alcoholism
• Review common medical complications
and their treatment in alcoholism
• Understand resources available for
treatment of alcoholism
Alcohol/Ethanol
• Mechanisms of Toxicity
– CNS depressant
– Teratogen
– Carcinogen
Basic Alcohol Physiology
• 25% enters the bloodstream from the
stomach, 75% from the intestine
• 90% to 98% is removed in the liver, and
the remainder is excreted by the kidneys,
lungs, and skin.
• 70-kg man can metabolize 5 to 10 g
ethanol per hour (average drink contains
12 to 15 g ethanol)-alcohol
dehydrogenase 90%
Blood Ethanol Levels
Blood Ethanol
Level
Sporadic Drinkers
Chronic
Drinkers
50-100
Euphoria,
gregariousness,
incoordination
Minimal or no effect
100-200
Slurred speech, ataxia,
labile mood,
drowsiness, nausea
Sobriety or
incoordination
Euphoria
200-300
Lethargy,
combativeness Stupor,
incoherent speech,
vomiting
Mild emotional and
motor changes
300-400
Coma
Drowsiness
>500
Death
Lethargy, stupor,
coma
adapted from Goldman: Cecil Textbook of Medicine, 21st ed., Copyright © 2000 W. B. Saunders Company
Medical Model of Alcoholism
• Signs:
• Heavy recurrent alcohol use and/or
intoxication
• Other drug use or unexpected drug
responses or interactions
• Trauma
• Absenteeism, presenteeism
• Personal neglect
Medical Model of Alcoholism
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Symptoms:
Nausea, vomiting
Unexplained diaphoresis
Tachycardia
Seizures, hallucinations
Withdrawal, tremors, blackouts
Depression, anxiety, sleep disturbance
Erectile dysfunction in men
Medical Model of Alcoholism
• Etiology: Familial-Heritability
estimated at 40-60%
• Less in certain populations
(i.e. southeast Asians)
• Possibly more damaging for women
Signs/Symptoms of Suspected
Alcoholic Patient in a Clinic Setting
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Fatigue
Absenteeism/Presenteeism
Depression/Anxiety/Psychosocial Issues
(Family History)
Obesity
Hypertension
Hepatomegaly
Gastrointestinal Complaints
None
Initial Laboratory Evaluation of
Suspected Alcoholic Patient
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Blood alcohol (drug screen)
LFT’s (GGTP)
elevated MCV
elevated triglycerides
These may be totally unrevealing….
Medical Complications
• GI tract/Liver: Fatty liver, hepatitis,
cirrhosis, esophagitis, gastritis
pancreatitis, cancers
• Nervous system: Brain: Hepatic
encephalopathy, Wernicke-Korsakoff
syndrome(thiamine deficiency), cerebellar
degeneration, central pontine myelinolysis,
dementia
Medical Complications
• Nutrition: Deficiencies of
Vitamins: Folate, thiamine, pyridoxine,
niacin, riboflavin
Minerals: Magnesium, zinc, calcium
Protein
• Metabolites and electrolytes
Hypoglycemia, ketoacidosis,
hyperlipidemia, hyperuricemia,
hypomagnesemia, hypophosphatemia
Medical Complications
• Neuromuscular: Neuropathy, myopathy
• Cardiovascular: Arrhythmia,
cardiomyopathy, Hypertension
• Bone marrow: Macrocytosis, anemia,
thrombocytopenia, leukopenia
Medical Complications
• Endocrine: Pseudo-Cushing's syndrome,
testicular atrophy, amenorrhea, DM?,
Osteopenia/osteoporosis
• Other cancers? (i.e., breast)
• Traumatic injury
• Fetal alcohol syndrome
Fetal Alcohol Syndrome
• 1 to 3 births per 1,000 world wide
• 1968 first association by French
researchers at the University of Nantes
• Early 1970’s FAS as condition –
University of Washington
• 4,000-12,000 infants per year in US
Fetal Alcohol Syndrome
• NO use of alcohol in pregnancy is safe
• Microcephaly, distinctive facial features,
developmental delay, behavioral
disorders.
• Occurs in about 6 percent of children of
alcoholic women
• Fetal alcohol effect-more common, more
subtle
Detoxification
and Withdrawal
Syndromes
Alcohol Overdose
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ABC’s
Oxygen, assisted ventilations
Intubate
IV, infuse fluid to support perfusion
Lavage if within 2 hours
Alcohol Overdose
– Dextrose, Oxygen, Narcan, Thiamine
– Glucose, thiamine (50-100mg)
– Narcan may reduce respiratory depression
but not CNS depression (? Use)
• Dialysis - removes 280mg/minute
Treatment of Initial Withdrawal
and Agitation
Benzodiazepines:
• Diazepam
• Lorazepam
• Chlordiazepoxide
Neuroleptics:
• Phenothiazines may be used as adjunct to
benzodiazepines
Detoxification
• Severe Withdrawal (Delirium Tremens)
occurs about 3-7%. High mortality. May
occur days after last use. BP, pulse good
indicators.
• Long acting benzodiazepines (Librium), IV
fluids, Thiamine, Multivitamin all started on
admission.
Co-Morbid Conditions
• Medical
• Psychiatric: Depression, Anxiety, or
Bipolar Disorder common
• SSRI’s have the most data in Treatment of
Depression in this population
Medical Treatment of
Alcoholism
Treatment of Alcoholism
• Traditional Inpatient/Outpatient
• 12 step: AA(oldest, common),
Specialty groups
• Medication
• Usually a combination of all 3
Medications for
Alcohol Dependence
• Three oral medications (approved)
-Naltrexone
-Acamprosate
-Disulfiram
• One injectable medication (approved)
-Extended-release injectable naltrexone
Medications for
Alcohol Dependence
• Topiramate (off label) Also used for
bipolar disorder
• Future directions
-Endocannibinoid receptor blockers
-Nicotinic receptor agonist/antagonist
• Combining medications uncertain benefit
Medication Management
• Consider in those failing typical psychosocial
approaches
• Used typically in those whose program
includes abstinence from alcohol
• Combining Medications and Behavioral
Interventions (COMBINE) clinical trial
-Benefit medications/counseling combined
• Medications usually prescribed
6 to 12 months
• Twice weekly brief counseling efficacious
Naltrexone
• Blocks opioid receptors
• Oral or injection
• 28% relapse rate vs 46% with placebo
Acamprosate
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GABA and glutamate receptors
17 clinical trials
36% abstinent vs 23% on placebo
Better results in European trials
(more dependent patients?)
• Can’t use in liver disease
Disulfuram
• Interferes with alcohol metabolism,
increases aldehyde concentrations results
in flushing, nausea, vomiting
• Poor compliance is typical
• Maybe better in short-term high-risk
situations
Topiramate
• GABA, glutamate receptors (?)
• Some efficacy in those not abstinent at
start of medication
• Used for other psych disorders
Alcohol Treatment
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Typically a cognitive-behavioral model
Motivational Interviewing
Stages of Change
Often incorporate some “12 step” concepts
“12 Step” Groups
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AA oldest, founded 1935
Founders were acquainted with Carl Jung
Mentoring (“sponsor”) encouraged
Not “group” therapy
Members are encouraged to seek outside
help, physician, clergy, psych, etc.
• No cost (voluntary donations)
Outcome Predictors
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Severity of addiction or withdrawal
Psychiatric Co-morbidity
Substance Related Problems
Multiple Substance Abuse
Length of Treatment
Genetic
Socio-Economic
Psychiatric Clinics N Am 26 (2003) 381–409
Summary
• Effective alcohol screening and guidelines
• Medications appropriate for some
• Medications not a substitute for traditional
psychosocial interventions/resources
• Combination of above likely more effective