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ALCOHOL DEPENDENCY & ABUSE (ALCOHOLISM)
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A Acute Intoxication
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The signs of alcoholic intoxication are the same as those of overdosage with any other central nervous system depressant: drowsiness, errors of commission, psychomotor dysfunction, disinhibition, dysarthria, ataxia, and nystagmus For a 70-kg person, an ounce of whiskey, a 4- to 6-oz glass of wine, or a 12-oz bottle of beer (roughly 15, 11, and 13 grams of alcohol, respectively) may raise the level of alcohol in the blood by 25 mg/dL For a 50-kg person, the blood alcohol level would rise even higher (35 mg/dL) with the same consumption Blood alcohol levels below 50 mg/dL rarely cause significant motor dysfunction Intoxication as manifested by ataxia, dysarthria, and nausea and vomiting indicates a blood level above 150 mg/dL, and lethal blood levels range from 350 to 900 mg/dL In severe cases, overdosage is marked by respiratory depression, stupor, seizures, shock syndrome, coma, and death Serious overdoses are frequently due to a combination of alcohol with other sedatives
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Physiologic dependence as manifested by evidence of withdrawal when intake is interrupted Tolerance to the effects of alcohol Evidence of alcohol-associated illnesses, such as alcoholic liver disease, cerebellar degeneration Continued drinking despite strong medical and social contraindications and life disruptions Impairment in social and occupational functioning Depression Blackouts
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Alcohol stigmas: alcohol odor on breath, alcoholic facies, flushed face, scleral injection, tremor, ecchymoses, peripheral neuropathy Surreptitious drinking Unexplained work absences Frequent accidents, falls, or injuries of vague origin; in smokers, cigarette burns on hands or chest Laboratory tests: elevated values of liver function tests, mean corpuscular volume, serum uric acid, and triglycerides
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B Withdrawal
There is a wide spectrum of manifestations of alcoholic withdrawal, ranging from anxiety, decreased cognition, and tremulousness through increasing irritability and hyperreactivity to full-blown delirium tremens Symptoms of mild withdrawal, including tremor, elevated vital signs, and anxiety, begin within about 8 hours after the last drink and usually have passed by day 3 Generalized seizures occur within the first 24 38 hours and are more prevalent in persons who have a history of withdrawal syndromes Delirium tremens is an acute organic psychosis that is usually manifest within 24 72 hours after the last drink (but may occur up to 7 10 days later) It is characterized by mental confusion, tremor, sensory hyperacuity, visual hallucinations (often of snakes, bugs, etc), autonomic hyperactivity, diaphoresis, dehydration, electrolyte disturbances (hypokalemia, hypomagnesemia), seizures, and cardiovascular abnormalities The acute withdrawal syndrome is often completely unexpected and occurs when the patient has been hospitalized for some unrelated problem and presents as a diagnostic problem Suspect alcohol withdrawal in every unexplained delirium The mortality rate from delirium tremens has steadily decreased with early diagnosis and improved treatment In addition to the immediate withdrawal symptoms, there is evidence of persistent longer-term ones, including sleep disturbances, anxiety, depression, excitability, fatigue, and emotional volatility These symptoms may persist for 3 12 months, and in some cases they become chronic
General Considerations
Alcoholism is a syndrome consisting of two phases: problem drinking and alcohol addiction Problem drinking is the repetitive use of alcohol, often to alleviate anxiety or solve other emotional problems Alcohol addiction is a true addiction similar to that which occurs following the repeated use of other sedativehypnotics Alcohol and other drug abuse patients have a much higher prevalence of lifetime psychiatric disorders While male-to-female ratios in alcoholic treatment agencies remain at 4:1, there is evidence that the rates are converging Women delay seeking help, and when they do they tend to seek it in medical or mental health settings Adoption and twin studies indicate some genetic influence Ethnic distinctions are important eg, 40% of Japanese have aldehyde dehydrogenase deficiency and are more susceptible to the effects of alcohol Depression is often present and should be evaluated carefully The majority of suicides and intrafamily homicides involve alcohol Alcohol is a major factor in rapes and other assaults There are several screening instruments that may help identify alcoholism One of the most useful is the CAGE questionnaire (see Table 1 10)
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