Alcohol

Alcohol abuse is very common and there’s a lot to discuss and know for the providers and your patients. If the person doesn’t drink, great but even with one drink, immediately try to rule out a problem or the potential. I treat substance use disorders (SUD) but also regularly screen patients for substance abuse issues. Screening also includes education, maybe the person is not aware of a problem or risks involved. For example, I’ll tell my patient, do you know more than 4 consistent drinks at any time is a huge risk for dependence? or if you have to take a shot first thing in the morning, it’ll lead to more poor coping skills and behaviors? Overall, try to catch or rule out a problem before it becomes an addiction.

The Standard Drink 

alcohol etoh standard drink

In the United States, the standard drink contains 0.6 US fluid ounces (18 ml) of alcohol. This is approximately the amount of alcohol in a 12-US-fluid-ounce (350 ml) glass of beer, a 5-US-fluid-ounce (150 ml) glass of wine, or a 1.5-US-fluid-ounce (44 ml) glass of a 40% ABV (80 US proof) spirit.

Normal Vs. Abnormal

I try to be brutally honest about addictions with my patients. Alcohol, in particular, is possibly the most dangerous because it’s the most insidious. A person doesn’t just wake up as an alcoholic. You have to look for risks and red flags to truly give the patient a clear picture of concerning behaviors.

Minors, pregnant women, or people with a dysfunctional liver are not supposed to have any form of ETOH. But if you’re able to drink, the recommended amount of drinking is <3 drinks/day for females and <4drinks/day for males and for everyone >65 no more than 3 drinks/day (NIAAA).  The CAGE screening is helpful to r/o problems and I also think about the following red flags: 

  • Living with an alcoholic or a hx of substance abuse/family hx
  • Mixing ETOH with medications or unusual habits/drinking coffee (an upper) with alcohol (the downer)
  • Taking someone else alcohol or stealing/hiding it, DUI’s, missing work
  • Having designated times to drink alcohol, habitual drinking patterns
  • Those who are in denial, minimize the risks and seriousness of drinking
  • Keeping alcohol at home, especially if living alone, I also questioned it with people who have families. Again, just assessing because I know it seems strict…

If a person still doesn’t think it’s a big deal, then I usually discuss a few of the many symptoms and diseases associated with ETOH:

  • Central nervous system depressant: relaxation progressing to slurred speech with impaired movement from stupor to anesthesia.
  • Nervous System: psychosis, seizures/trembling, Wernicke’s Korsakoff’s syndrome secondary to dementia, memory loss, ataxia, confusion (thiamine, niacin deficiencies)
  • Cardiac: arrhythmias, myopathy, HTN
  • GI: gastritis, heartburn, cirrhosis, pancreatitis -> diabetes, hypoglycemia, ulcers, esophageal varices, CA
  • Respiratory: COPD, pneumonia, CA
  • Genitourinary: fetal alcohol syndrome, erectile dysfunction/decreased libido
  • Skin/Muscle: ulcers, spider angiomas, fractures, excessive bruising

Low-Moderate Drinkers

  • Stress Management: encourage healthier ways to cope or handle stress, and promote healthy eating and exercise.
  • Treat Mood, Mental Symptoms: target anxiety, restlessness, and poor sleep.
  • Encourage Harm Reduction: goals for those at low risk or with less severe drinking issues. Contraindicated conditions for harm reduction that will be exacerbated by alcohol or those who need to have a complete cessation of ETOH, i.e. disulfiram, opioids, those who are pregnant or breastfeeding, hx of severe alcohol withdrawal symptoms.

More Serious Symptoms

  • Alcohol Withdrawal Symptoms: physical manifestation developing 6-8 hours post drink, shakiness, anxiety, mood swings, insomnia, impaired appetite, elevated vital signs, confusion
  • Alcohol Withdrawal Delirium: an acute medical condition that can be fatal occurring 2-4 days after last drink, s/s: confusion, disorientation, visual and auditory hallucinations, convulsions. The best care is early detection and inpatient detoxification (3-7 days) to medically manage withdrawals and prevent DT’s. TX with CIWA protocols, fluids, vitamins, treat GI symptoms, seizure precautions, decrease stimuli, high protein, carb/low-fat diet.

After Care & Long-Term Treatment/Support

  • Therapy: try to have an addiction specialist or someone who specializes with addictions for the best results. I’ve had patients who went to regular therapists and it’s NOT the same. People with addictions know how to manipulate and will take advantage of the situation, I don’t mean to make assumptions but take precautions.
  • AA meetings: Even if the person is not religious, AA is a great option. Most people with addictions lost their jobs, family, and friends. AA offers FREE and accessible sponsors and support and you want to build this person’s support system to stay sober. Other Support/Community Options: SMART Recovery®, LifeRing Secular Recovery, Secular Organizations for Sobriety, Women for Sobriety, and Mothers Against Drunk Driving (MADD).
  • 3/4 house: is considerably less structured and rigorously controlled than a halfway home. Generally speaking, you’ll have later curfews, the ability to go out on overnight passes, and even start going to work or school. –Vertava Health

(Common) Pharmacological Meds

  • Acamprosate/1st Line: “artificial alcohol” is approved for alcohol abstinence and is used only for people who have achieved abstinence. Contraindicated with severe renal impairment and not metabolized by liver enzymes. Dosed tablet 333mg, either 666mg 3x/day>60kg or 666mg 2x/day<60kg (so yes many pills, make sure the patient is aware).
  • Disulfiram/1st Line: an alcohol antagonist drug. Dosed 250-500/day, usually in the morning but may have sedating effects. 1-year duration. Education is huge: have to be 12 hours from last drink to start. reaction up to 2 weeks may occur if stopped. AVOID food, drink, and items with alcohol, I also usually say avoid mouthwash, sanitizers, colognes/perfumes…etc. Contraindicated if taking metronidazole, amprenavir, ritonavir, or sertraline and in psychosis, heart disease. Not recommended for >60y/o, pulmonary disease, renal failure, diabetes, peripheral neuropathy, SZ, cirrhosis, or portal HTN.
  • Naltrexone/1st Line: good for long-term abstinence and reducing the cravings/drinking. Naltrexone blocks the mu-opioid receptors, which are supposed to block the euphoria people get from drinking/opioids. Dosed 25-100mg/day or 380mg/4 weeks. Adherence is best with the injectable. But patients do report the shot not lasting long enough, which puts them at risk for relapse.
  • Topiramate (2nd Line): Helpful for achieved abstinence or who is trying, decreasing ETOH use, or adjunct. Approved for SZ disorders and migraine prophylaxis. S/E: sedation, n/v, weight loss, may cause metabolic acidosis or kidney stones. Dosed up to 300mg/day with slow titration to reduce s/e.

–Stahl’s Illustrated

Outpatient Detox: diazepam, chlordiazepoxide, clonazepam. Pros: longer-acting (a smother withdrawal). Cons: can be addictive, Valium and Librium requires liver metabolism. Phenobarbital is recommended due to being safer if there’s liver damage and a very long 1/2 life (100 hours).  Start with a loading dose 15mg x2 q6 hours, then decrease by a pill/per day, after day 9 or 15mg QD, then it’s one tab every other day until it can be d/c as tolerated. However, this physician is seeing clients <weekly and this isn’t feasible in a monthly f/u or just very rare in community mental health so I wouldn’t recommend this option unless it’s a private practice or something flexible. 

Non-sedatives for Detox: gabapentin and carbamazepine

Comfort Meds: if the sedation is appropriate “comfort meds” shouldn’t be necessary for detox

  • Nausea: metoclopramide 10mg, ondansetron 4mg
  • Insomnia: trazodone 50mg, diphenhydramine 50mg
  • Anxiety: clonidine

MAT for ETOH:

  • Naltrxone: reduces cravings, “it doesn’t make you feel bad if you drink, it just doesn’t let drinking make you feel good”. Common s/e nausea, self-limiting or take it with food.
  • Injectable: avoid with opioid use, a dog tag is provided, and lower dose if there are liver issues.
  • Acamprostate: decrease cravings, s/e loose stools, not affected by the liver, lower dose for significant kidney issues. A pill burden; 333mg x2 pills, 3 times a day and the pills are large.
  • Disulfiram: 500mg QD, a lower dose (250mg) for people with liver disease, it can also worsen psychotic symptoms. Contraindicated for people with heart disease.

-Carlat Guides

Medicines To Treat Alcohol Use Disorder

Your doctor may suggest a medicine to help treat your alcohol use disorder. Medicines are usually used together with talk therapy and support groups.

  • Acamprosate (Campral®): This medicine was approved by the U.S. Food and Drug Administration (FDA) to treat alcohol dependence*. It helps rebalance chemicals in the brain that may be changed by drinking too much.
  • Disulfiram (Antabuse®): This medicine was approved by the FDA to treat alcohol dependence*. If you drink alcohol, this medicine causes unpleasant effects, such as nausea, vomiting, headache, flushing (reddening of the face, neck, or chest), sweating, and chest pain. These effects can last for an hour or longer.
  • Naltrexone (Revia®, Vivitrol®): This medicine was approved by the FDA to treat alcohol dependence*. It works by decreasing the craving for alcohol.
  • Topiramate (Topamax®, Trokendi XR®, Qudexy XR®): This medicine was approved by the FDA to treat seizures and prevent migraine headaches. Some doctors also use it to treat alcohol use disorder. It helps rebalance chemicals in the brain and helps correct the electrical activity of brain cells.

–SAMHSA (additional s/e and how to treat ETOH)

Personal Experience

Chronic ETOH users are well aware of the common medications for ETOH and from my experience, they usually refuse so I make sure the plan of care is very patient-centered. Relapse is less likely when patients are MORE engaged and in control of their own care and recovery. In other words, I hold the person accountable to do the work to stay sober. I do offer the MATS option on the follow-ups or let people know to just call if they change their mind.

Guide and support the person to be responsible for their own decisions and recovery. I tell my patients the ones who don’t relapse are the ones most engaged in their recovery and adhere to the f/u treatment.

Again, try to hash out what didn’t help and reiterate how they need to be more involved to proceed.

Sometimes I’ll tell the patient just use the medications to get over the hump it doesn’t have to be forever. I do plan on writing up my bootleg psychotherapy in the near future but here are the medications I normally use when people have alcohol disorders and the liver is still intact:

  • Target Sleep/Nightmare: quetiapine (also helps with nightmares but too high of a dose may cause them),  clonidine (can also reduce nightmares, helps with cravings), olanzapine (increase dose with smokers because I generally avoid it with them), other medications; trazodone, mirtazapine, doxepin (caution with increase BP), hydroxyzine (also helps with nightmares, increase sleep).
  • Target Anxiety/Cravings: clonidine, valproate (caution with liver issues), hydroxyzine, bupropion (tx ADHD, caution for seizure risks), gabapentin, buspirone.
  • Target Depression: fluoxetine (for PTSD, grief, crying spells), desvenlafaxine (renal excreted/avoids liver metabolism), SSRIs to target depression (I personally avoid TCA’s in this population due to impulse concerns).
  • Mood Disorder: VPA, lamotrigine, usually I avoid lithium (or things that may be high maintenance) unless they were already using it.
  • Complementary: vitamin B12, magnesium/multivitamin, support groups, therapy (CBT, MET, behavioral/family therapy, IPT, self-help/12-step per Stahl)

Other Considerations

  • Impaired Liver: if we’re not sure that the liver is okay then take precautions. Read the writing on the wall, if someone continuously relapses, has poor impulses/coping skills, frequent falls/injuries, ulcers, pancreatitis, etc. I will err on the safe side with certain medications. VPA can take the edge off but is contraindicated with liver impairment, most anticonvulsants, antidepressants, and meds, in general, have liver warnings… Duloxetine and nefazodone can cause liver failure, so I usually go with sertraline, desvenlafaxine, or newer agents for depression/anxiety treatment. I also somewhat avoid bupropion due to the seizure risks and how ETOH needs to be AVOIDED. Some patients had good past experiences with it but it’s not my first line.
  • Suggest a Multivitamin: people with chronic alcoholism are drinking their calories so they’re becoming deficient in nutrients. I at least recommend supplementing with vitamins, in particular, thiamine r/t Wernicke–Korsakoff syndrome. There are other deficiencies that are caused by ETOH; vitamin D, calcium, magnesium, RBCs, etc. I just try to reinforce healthy eating and/or supplements.
  • About Fake ETOH: I have patients that drink “non-alcoholic” beverages (yes it’s such a thing because I didn’t know lol). It’s like carbonated water or whatever and I just tell patients it’s a slippery slope. Most of the time (more like every time) it leads to a relapse. I get the concept, like it’s vaping, methadone, or trying to avoid the “real” substances. However, for people who are really struggling or have a dependence, this should be discouraged because they WANT the “real thing” and will get frustrated/relapse. I’m also worried about the acid content and varices/GERD risks. For moderate to low/no drinkers who just want the taste, it shouldn’t be a major issue.
  • Encouraged PCP F/U: there’s a whole host of issues with chronic alcoholism that needs to be ruled out or managed by their general practitioner. I avoid discussing the benefits because it’s just too many risks, especially in psych:

etoh long term

Resources & Additional Materials

Alcohol Rehab Guide/Centers & Addiction Group: Causes of Alcohol Use Disorder/AUD & Alcohol Addiction Rehabilitation Treatment (requested website added)

Alcohol Screening and Brief Intervention for Youth: A (PDF) Practitioner’s Guide by SAMHSA

National Institute on Alcohol Abuse and Alcoholism (NIAAA) & Policies about ETOH: also affiliated with the following links:

What Alcohol Does to Your Body?: An awesome YouTube video that breaks down how alcohol affects your body.

Specialists in alcohol-related treatment

For specialists in alcohol-related treatment, contact your doctor, health insurance company, local health department, or employee assistance program, or the Treatment Facility Locator (1-800-662-4357). In addition, these professional organizations can help you find medical or non-medical specialists for alcohol use disorder in your area:

Mutual-support groups

Groups for family and friends

 

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