Description

• Any pattern of alcohol use causing significant physical, mental, or social dysfunction. Key features are tolerance, withdrawal, and persistent use despite problems.
• Alcohol abuse: maladaptive pattern of alcohol use manifested by one or more of the following:
  • Failure to fulfill obligations at work, school, or home
  • Recurrent use in hazardous situations
  • Recurrent alcohol-related legal problems
  • Continued use despite related social or interpersonal problems
• Alcohol dependence: maladaptive pattern of use manifested by ≥3 of the following:
  • Tolerance; withdrawal; using more than intended
  • Persistent desire or attempts to cut down/stop
  • Significant amount of time obtaining, using, or recovering from alcohol
  • Social, occupational, or recreational activities sacrificed for alcohol use
  • Continued use despite physical or psychological problems
• National Institute on Alcohol Abuse and Alcoholism criteria for “at-risk” drinking: men: >14 drinks a week or >4 per occasion; women: >7 drinks a week or >3 per occasion
• The 2015-2020 Dietary Guidelines for Americans defines moderate drinking as up to 1 drink per day for women and up to 2 drinks per day for men.
• In the US, a standard drink (also known as an alcoholic drink-equivalent) is defined as any beverage containing 0.6 fl oz or 14 g of pure alcohol.
• Women experience harmful effects at lower levels of alcohol consumption and are less likely to report problems related to drinking.
• System(s) affected: nervous, gastrointestinal (GI)
• Synonym(s): alcoholism; alcohol abuse; alcohol dependence

Geriatric Considerations

• Common and underdiagnosed in elderly; less likely to report problem; may exacerbate normal age-related cognitive deficits and disabilities
• Multiple drug interactions
• Signs and symptoms may be different or attributed to chronic medical problem or dementia.
• Common assessment tools may be inappropriate.

Pediatric Considerations

• Children of alcoholics are at increased risk
• 2.5% of adolescents have alcohol use disorder (AUD); 13.4% of youth age 12 to 20 years report binge drinking in the past month; negative effect on maturation and normal brain development
• Early onset drinkers (those who start drinking before age 21 years) are 4 times more likely to develop a problem than those who begin after age 21 years.
• Depression, suicidal or disorderly behavior, family disruption, violence or destruction of property, poor school or work performance, sexual promiscuity, social immaturity, lack of interests, isolation, moodiness

Pregnancy Considerations

• Women should abstain if attempting conception and throughout pregnancy.
• 10–50% of children born to women who are heavy drinkers will have fetal alcohol syndrome.

Epidemiology

• Predominant age: 18 to 25 years, but all ages affected
• Predominant sex: male > female (3:1)

• 27% of Americans age 18 years or older reported binge drinking in the past month; 7% reported heavy alcohol use in the past month.
• 15 million adults (6%) age >18 years has AUD.

Etiology and Pathophysiology

• Multifactorial: genetic, environment, psychosocial
• Alcohol is a CNS depressant, facilitating γ-aminobutyric acid (GABA) inhibition and blocking N-methyl-D-aspartate receptors.

Genetics
50–60% of risk is genetic.

Risk Factors

• Family history
• Depression (40% with comorbid alcohol abuse)
• Anxiety disorders; bipolar disorder; eating disorders
• Tobacco use; other substance abuse
• Male gender; lower socioeconomic status
• Unemployment
• Poor self-esteem—seeking peer/social approval
• Family dysfunction or childhood trauma
• Posttraumatic stress disorder
• Antisocial personality disorder
• Criminal behavior

General Prevention

Counsel patients with family history and risk factors.

Commonly Associated Conditions

• Cardiomyopathy, atrial fibrillation
• Hypertension
• Peptic ulcer disease/gastritis
• Cirrhosis, fatty liver, cholelithiasis
• Hepatitis; pancreatitis
• Diabetes mellitus
• Malnutrition; upper GI malignancies
• Peripheral neuropathy, seizures
• Abuse and violence
• Trauma (falls, motor vehicle accidents [MVAs])
• Behavioral disorders (depression, bipolar, schizophrenia): >50% of patients with these disorders have a comorbid substance abuse problem.