Alcohol Use Disorders: Alcohol Abuse and Dependence

1. Concepts and principles related to alcohol abuse and dependence:
   • Alcohol affects cerebral cortical functions:
     1. Memory.
     2. Judgment.
     3. Reasoning.
   • Alcohol as a depressant:
     1. Relaxes the individual.
     2. Lessens use of repression of unconscious conflict.
     3. Releases inhibitions, hostility, and primitive drives.
   • Drinking represents a tension-reducing device and a relief from feelings of insecurity. Strength of drinking habit equals degree of anxiety and frustration intolerance.
   • Alcohol abuse and dependence is a symptom rather than a disease.
   • Underlying fear and anxiety, associated with inner conflict, motivate the alcoholic to drink.
   • Alcoholics can never be cured to drink normally; cure is to be a “sober alcoholic,” with total abstinence.
   • The spouse of the alcoholic often unconsciously contributes to the drinking behavior because of own emotional needs (co-alcoholic or co-dependent).
   • Intoxication occurs with a blood-alcohol level of 0.08% or above. Signs of intoxication are:
     1. Incoordination.
     2. Slurred speech.
     3. Dulled perception.
   • Tolerance occurs with alcohol dependence. Increasing amounts of alcohol must be consumed to obtain the desired effect.
   
   
2. Assessment:
• Vicious cycle - (a) low tolerance for coping with frustration; tension, guilt and shame, resentment; (b) uses alcohol for relief; (c) new problems created by drinking; (d) new anxieties; and (e) more drinking.
• Coping mechanisms used: denial, rationalization, projection.
• Complications of abuse and dependence.
  1. Alcohol withdrawal delirium (delirium tremens [DTs]) (Figure 6-5)—result of nutritional deficiencies and toxins; requires sedation and constant watchfulness against unintentional suicide and convulsions.
     • Impending signs relate to CNS - marked nervousness and restlessness, increased irritability; gross tremors of hands, face, lips; weakness; also cardiovascular - increased blood pressure, tachycardia, diaphoresis, dysrhythmias; depression; gastrointestinal - nausea, vomiting, anorexia.
     • Actual - serious symptoms of mental confusion, convulsions, hallucinations (visual, olfactory, auditory, tactile). Without treatment, 15-25% may die due to cardiac dysrhythmias, respiratory arrest, severe dehydration, massive infection.
  2. Wernicke’s syndrome - a neurological disturbance manifested by confusion, ataxia, eye movement abnormalities, and memory impairment. Other problems include:
     • Disturbed vision (diplopia).
     • Wandering mind.
     • Stupor and coma.
  3. Alcohol amnestic syndrome (Korsakoff’s syndrome) - degenerative neuritis due to thiamine deficiency.
     • Impaired thoughts.
     • Confusion, loss of sense of time and place.
     • Use of confabulation to fill in severe recent memory loss.
     • Follows episode of Wernicke’s encephalopathy.
  4. Polyneuropathy - weak, irregular, rapid peripheral pulses; sensory and motor nerve endings are involved, causing pain, itching, and loss of limb control.
  5. Related concerns - chronic heart failure (generalized tissue edema), gastritis, esophageal varices, cirrhosis, pancreatitis, diabetes, pneumonia, REM sleep deprivation, malnutrition.
• Diagnostic tests
  1. Blood tests:
     • CBC: decreased Hgb/Hct to detect irondeficiency anemia or acute/chronic GI bleeding; increased WBC (infection); decreased WBC (if immunosuppressed).
     • Glucose: hyperglycemia/hypoglycemia may be present (pancreatitis, malnutrition, or depletion of liver glycogen stores).
     • Electrolytes: decreased potassium and magnesium.
     • Liver function tests: increased CPK, LDH, AST, ALT, and amylase (liver or pancreatic problem).
     • Nutritional tests: decreased albumin and total protein; decreased vitamins (malnutrition/malabsorption).
  2. Urinalysis: infection; ketones due to breakdown of fatty acids in malnutrition (pseudodiabetic condition).
  3. Chest x-ray: rule out right lower lobe pneumonia (related to malnutrition, depressed immune system, aspiration).
  4. ECG: dysrhythmias, cardiomyopathies, or ischemia due to direct effect of alcohol on the cardiac muscle or conduction system, as well as effects of electrolyte imbalance.
  5. Other screening studies (e.g., hepatitis, HIV, TB): dependent on general condition, individual risk factors, and care setting.I