An Introduction to Diagnosis and Treatment of Alcoholism

Marc A. Schuckit, M.D.

Prepared November 10, 2000

1. Introduction

This lecture is aimed at helping healthcare providers recognize alcohol-related problems among their patients and clients.

1. You might start with a graphic representation of how individuals can develop a condition

where normal day-to-day activities (figuratively, including tying your shoes) can be impaired. The recognition and treatment of alcohol-use disorders can be challenging, in part because these are highly prevalent conditions that can affect both genders, all races, and individuals from all socioeconomic strata (Lowinson et al., 1996; Schuckit, 2000).

2. Slide 1 reminds the student that it is important to distinguish between drinking (90% or

so of the population have ever consumed alcohol), potentially temporary problems (seen in almost half of drinkers), and more persistent problems that might be termed abuse or dependence. Each of these issues is important, and even low levels of alcohol consumption can be dangerous in the context of pregnancy, a variety of medical problems, or while taking any of a wide range of medications.

3. Slide 2 highlights the fact that alcohol consumption produces costly problems for society. On the other hand, as opposed to nicotine, for which there are few if any positive health effects, low doses of alcohol (at most two standard drinks per day) in individuals who are not otherwise proscribed from drinking does have some healthful benefits, including a potential decrease in the risk for heart attack and ischemic stroke, decreases the risk for gallstones, and increases appetite and social interactions. All of these benefits disappear and reverse at higher doses of alcohol. A standard drink is defined as approximately 10 grams of ethanol, or the amount found in approximately a 12-ounce beer, four ounces of nonfortified wine (there are between five and six drinks in the usual bottle of wine), or a single shot (1.5 oz.) of 80-proof beverage.

II. Alcohol Use Disorders Can Be Defined, and Their Usual Clinical Course Described. 2. Slide 3 demonstrates the DSM criteria for dependence. These can be paraphrased as a

demonstration of repetitive problems with alcohol in multiple life areas. This implies that the individual continues to consume the substance despite repetitive problems – a characteristic that is an excellent predictor of the high risk for future difficulties (American Psychiatric Association, 1994). Note that it is important to distinguish between alcohol-dependent individuals with and without a physiological component (i.e., tolerance or withdrawal), as this relates to more severe and less severe clinical pictures (Schuckit et al., 1998a).

3. Slide 4 outlines the criteria for abuse. This disorder can only be diagnosed in the

absence of dependence on the same drug, and the label rests with the documentation of repetitive problems in at least one of four life areas, including role obligations, repetitive use of alcohol in

hazardous situations, recurrent legal problems, and the continuation of alcohol intake despite difficulties.

4. Slides 5 and 6 outline important aspects of the usual clinical course of alcoholism

(Schuckit et al., 1998b; Schuckit, 2000).

1. The age of onset of use and first temporary problems are similar as those noted in non-alcohol dependent individuals.

2. While alcohol dependence can develop at any age, it is usually first documented as a syndrome involving three or more areas of life problems in the mid-20s to approximately age 40.

3. Even highly functional, higher educated, alcohol- dependent individuals cut 15 years off their life span, with leading causes of death (in descending order) being heart disease, cancer, accidents, and suicide. The lecturer might use these data as an opportunity to briefly review the effects of alcohol on body systems, explaining why the increased risks for heart disease and cancer occur. It is also important to emphasize that only 15% of alcoholics have cirrhosis, and, thus, while this disorder is much more common in alcoholics than the general population, it is not a leading cause of death.

4. It is important that the fluctuating course of alcohol abuse and dependence be

emphasized. Individuals typically develop alcohol-related problems; these result in some sort of crisis; the alcoholic stops drinking spontaneously (with usually only minor withdrawal symptoms observed); they then stay abstinent for some extended period of time (days up to years); finally, they return to drinking by usually setting up rules to help them control their intake. However, once alcohol is consumed it is usually only a matter of time (albeit days to months) until alcohol use and problems escalate once again (Schuckit et al., 1997a).

5. It is also important to emphasize that there is at least a 20% spontaneous

remission rate among alcohol-dependent people. Thus, five-year or longer followups of alcoholic individuals demonstrate a substantial proportion have stopped drinking and remained abstinent, even in the absence of self- help groups or formal treatment. Thus, there is hope for recovery, even among individuals who have refused to enter treatment.

6. More information and additional lecture material and slides regarding physiological problems associated with the course of alcoholism can be found in the lecture by Raimo on the Alcohol Medical Scholars Program web site (www.alcoholmedicalscholars.org).

D. Time permitting, it is worthwhile to review the high rate of temporary conditions of anxiety, depression, insomnia, and even psychosis among alcohol-dependent people.

1. Slide 7 notes that while two out of three alcohol-dependent people meet

criteria for another psychiatric diagnosis, one-half of those two-thirds have either the antisocial personality disorder (ASPD) and/or another substance dependence diagnosis. The one-third of alcohol-dependent individuals who meet criteria for an Axis I label, are usually experiencing a temporary substance-induced disorder. Alcohol-dependent people do have higher than expected rates of independent schizophrenia, bipolar manic- depressive disease, and the antisocial personality disorder.

2. Slide 8 presents a time line, which might be used as an example in discussing these issues of comorbidity with students (Schuckit et al., 1997b; Schuckit et al., 1997c; Schuckit et al., 2000).

III. A Brief Outline of Steps Important in Screening For Alcohol Use Disorders.

A. A key step is to drop all stereotypes of what an alcohol-dependent individual is. Alcoholics come from all backgrounds. For example, a 15-year followup of over 453 students at the University of California, San Diego demonstrated that even though a large majority graduated from college and received post-graduate degrees, the rate of alcohol abuse or dependence in this population was approximately 20% (about 35% for sons of alcoholics) (Schuckit and Smith, 2000).

1. Slides 9 and 10 demonstrate that the initial screening for an alcohol use disorder

recognizes that the diagnosis rests with evidence of impairment in life functioning. Therefore, the clinician should begin by asking all patients and clients about functioning in interpersonal, job, health, legal, driving, etc. realms – then probing to see whether alcohol might have contributed to the picture.

2. For alcohol, a number of state markers of heavy drinking can be useful. Here, blood tests

can identify values that, while still often within the normal range, are high enough to raise the suspicion that an individual might be drinking four, six or more drinks per day on a regular basis. While these do not diagnose alcohol abuse or dependence, they do indicate patients from whom additional information should be obtained to rule out an alcohol use disorder. Note that the appropriate cutoff for GGT is 35 (with 50 often being used as a screen for liver disease), and that the red blood cell size (MCV) cutoff of 92 is still within the normal range – but high normal. Of course, the usual liver function tests can also be useful, but these have less sensitivity. The state markers listed in this slide include sensitivities and specificities of approximately 70% for GGT and CDT, although the figures are closer to 50% for MCV.

3. Slide 11 outlines a number of simple self-administered questionnaires that can be used

to help screen for potential alcohol-related problems in the office. None of these are a substitute for a good clinical evaluation, but they can identify people who have had problems in multiple life problems. It is probably worthwhile to use more complete instruments, such as the 25-item

Michigan Alcohol Screening test, that ask individuals about a variety of practices and potential problems related to alcohol. This 25-item questionnaire takes less than five minutes to fill out. IV. Intervention

A. Once an alcohol use disorder has been identified, the potential problem must be shared with the patient or client. As shown in Slide 12, this process is termed intervention.

B. Each clinician will develop his or her own style of intervention.

C. The key is to focus on specific problems that can be highlighted for the individual. The patients are told that they must make some decisions for themselves, but if they continue to take alcohol, a large number of predictable problems are likely to develop. These can be briefly shared with the individual using information regarding the usual clinical course as is described above, and from the Raimo et al. lecture.

D. An intervention is usually a repetitive process, and the clinician is advised to continue to bring up his or her concerns whenever they see the patient until he or she is willing to take action.

E. The lecturer might choose to briefly discuss a more intensive intervention where all family members and friends gather together to share their concern with the patient – a process called the Johnston Institute approach. This procedure has both assets and liabilities, and should not be used routinely.

V. Stages of Treatment

A. Patients who agree to enter treatment then face a series of potential stages of treatment which are briefly outlined in Slide 13.

B. The first step involves the recognition and treatment of alcoholic withdrawal.

1. As shown in Slide 14, the syndrome of withdrawal is typical of all brain

depressants and, thus, resembles withdrawal from benzodiazepines and barbiturates. The core of symptoms is the fact that they are the opposite of the acute effects of alcohol in the first place, and include insomnia, anxiety, and autonomic nervous system hyperactivity.

2. Because alcohol is a short half-life drug, symptoms are usually observed within

eight hours or so of decreasing blood alcohol levels, these peak in intensity on approximately day two, and are greatly improved by day five.

3. However, withdrawal symptoms continue at a less intense level for as much as

three to six months after withdrawal. These lingering problems include mood swings, evidence of mild autonomic over-activity, and insomnia.

4. Less than five percent of individuals undergoing alcohol withdrawal demonstrate

a grand mal convulsion (usually only one or two) or a severe agitated delirium (known as delirium tremens or DTs) (Schuckit et al., 1995). The lecturer might choose to spend some time talking about the treatment of withdrawal convulsions (anticonvulsants are not appropriate, and the benzodiazepines alone are enough), and the optimal approach for dealing with a delirium (involving the judicious use of either benzodiazepines or antipsychotic drugs for the three-to-five days that the DTs continue).

5. The treatment of withdrawal is straightforward and has been described in many

textbooks (Lowinson et al., 1996; McLellan et al., 2000; Schuckit, 2000). The steps are briefly described in Slide 15.

1. An essential step is a thorough physical examination. Entering

withdrawal from a brain depressant drug while suffering from medical problems is likely to markedly increase the risk for seizures or DTs.

2. The patient should be reassured that this is a three-to-five day acute

phenomenon and that the clinician knows how to treat it.

3. Multivitamins should be prescribed orally. There are actually very few

alcoholics who are vitamin deficient, but oral multivitamins make sense. 4. While not listed on the slide, it is very important to avoid using IV fluids

unless there is a compelling medical reason. Most alcohol- dependent individuals are overhydrated (not dehydrated) when they enter treatment for withdrawal, and a fluid overload can result in signs of congestive heart failure.

5. All withdrawal symptoms can be markedly alleviated with administration

of a brain depressant drug, allowing the patient to become comfortable on day one and then decreasing the dose by approximately 20% of the first day’s level over each subsequent day, reaching zero medications by approximately day five. An example is to begin with chlordiazepoxide (Librium) orally, using 25 mg. four times a day on day one, telling the patient to skip doses if they are too tired, and to take at most one or two extra 25 mg. doses during the day if needed. The patient is then re- evaluated on day two to determine whether it is possible to go down by 20% of that initial day’s dose, and so on. There are no data to indicate that more expensive and potentially more dangerous approaches, including carbamazepine (Tegretol) or the newer generation anticonvulsant medications (which are also brain depressants) work any better than the benzodiazepines, and these newer approaches are more expensive and pose a risk for more serious side effects.

C. Slide 16 gives an overview of the key elements of rehabilitation for any chronic disorder. Thus, there are important parallels between the rehabilitation efforts aimed at alcohol dependence, and those focused on other drugs, or other chronic conditions such as diabetes or hypertension (McLellan et al., 2000).

6. The approach to treatment has been described in detail in many textbooks (e.g.,

Schuckit, 2000). Only a brief outline will be given here. Additional information and slide copy are available in the lectures by Bierut and by Modesto-Lowe on the Alcohol Medical Scholars Program web site (www.alcoholmedicalscholars.org).

7. Group therapy, lectures, and one-to-one interventions are used to help individuals

increase their motivation for abstinence, to help them rebuild their lives without alcohol, and to establish relapse prevention. 8. Slide 17 discusses a number of potential medications for use in the treatment of alcohol dependence. None of these have been shown to be cost effective, although there are modest gains in outcome associated with naltrexone and acamprosate. The lecturer might choose to give more information on these medications, using the resources offered in some of the references (e.g., Schuckit, 2000), as well as the lecture material by Modesto-Lowe on the Alcohol Medical Scholars Program web site.

VI. Etiology

A. Time permitting, the lecturer might choose to briefly review some of the potential causes of alcohol use disorders.

B. A major emphasis might be placed on genetic factors that impact on the alcoholism risk.

C. Slide 18 outlines some of the issues that might be discussed, including the data that demonstrate alcohol dependence is genetically influenced, as well as data related to markers of the alcoholism risk, including the low level of response to alcohol. Details that might be used for this aspect of the lecture, as well as slide copy are given on the Alcohol Medical Scholars Program web site as part of the lecture on the genetics of alcoholism by Schuckit.

VII. Bibliography

1. Lowenson JH, Ruiz P, Millman RB, Langrod JG: Substance Abuse, Third Ed. Baltimore. Williams and Wilkens, 1996.

2. McLellan AT, Lewis DC, O’Brien CP, Kleber HD: Drug dependence, a chronic medical illness: implications for treatment, insurance and outcomes evaluation. JAMA 2000; 284:1689-1695.

3. Schuckit, MA: Drug and Alcohol Abuse: A Clinical Guide to Diagnosis and Treatment, Fifth Ed. Kluwer Academic/Plenum Publishers, 2000.

4. Schuckit MA, Daeppen J-B, Tipp JE, Hesselbrock M, Bucholz KK: The clinical course of alcohol-related problems in alcohol dependent and nonalcohol dependent drinking women and men. J Stud Alcohol 1998b; 59:581-590.

5. Schuckit MA, Smith TL: The relationships of a family history of alcohol dependence, a low level of response to alcohol, and six domains of life functioning to the development of alcohol use disorders. J Stud Alcohol 2000; 61:827-835. 6. Schuckit MA, Smith TL, Daeppen J-B, Eng M, Li T-K, Hesselbrock VM, Nurnberger JI, Bucholz KK: Clinical relevance of the distinction between alcohol dependence with and without a physiological component. Am J Psychiatry 1998a; 155:733-740.

7. Schuckit MA, Smith TL, Radziminski S, Heyneman EK: Behavioral symptoms and psychiatric diagnoses among 162 children in nonalcoholic or alcoholic families. Am J Psychiatry 2000; 157:1881-1883.

8. Schuckit MA, Tipp JE, Bergman M, Reich W, Hesselbrock VM, Smith TL: Comparison of induced and independent major depressive disorders in 2,945 alcoholics. Am J Psychiatry 1997b; 154:948-957.

9. Schuckit MA, Tipp JE, Bucholz KK, Nurnberger Jr. JI, Hesselbrock VM, Crowe RR, Kramer J: The l ife-time rates of three major mood disorders and four major anxiety disorders in alcoholics and controls. Addiction 1997c; 92:1289-1304.

10. Schuckit MA, Tipp JE, Reich T, Hesselbrock VM, Bucholz KK: The histories of withdrawal convulsions and delirium tremens in 1648 alcohol dependent subjects. Addiction 1995; 90:1335-1347.

11. Schuckit MA, Tipp JE, Smith TL, Bucholz KK: Periods of abstinence following the onset of alcohol dependence in 1,853 men and women. J Stud Alcohol 1997a; 58:581-589.

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