Withdrawal Approximately 8 to 12 hours after consuming alcohol, the body’s reaction to poisoning and withdrawal from alcohol, known as a hangover, begins. This reaction varies in severity based on the amount of alcohol consumed as well as individual factors, and can include headache, nausea, vomiting, fatigue, and depression. While there are a number of home remedies thought to help prevent or relieve hangovers, limiting the consumption of alcohol is the only effective remedy. Eating a full meal before drinking alcohol and alternating alcoholic drinks with non-alcoholic drinks can limit absorption. 205 Chronically heavy drinkers who suddenly decrease or stop consuming alcohol may experience alcohol withdrawal. Alcohol withdrawal symptoms typically peak within 24 to 72 hours of the last drink, and can continue for weeks. Common symptoms include irritability, anxiety, depression, mood swings, nightmares, fatigue, and confusion. Other symptoms, such as rapid heart rate, sweating, tremor, insomnia, loss of appetite, nausea and vomiting can occur. Severe withdrawal can cause agitation, seizures, hallucinations, and delirium. 207 Patients at risk of developing complicated alcohol withdrawal should be closely monitored. Seizures can occur within 8 to 48 hours after stopping or reducing alcohol use, with risk peaking at around 24 hours. An impending seizure can produce signs such as high blood pressure, high pulse, tremors, high temperature, or overactive reflexes, though seizures can occur without warning as well. Patients who have experienced one alcohol withdrawal seizure are at a higher risk of having another seizure or progressing to alcohol withdrawal delirium. 171 Delirium is an acute state of confusion with impaired cognition that can occur during alcohol withdrawal. It is associated with increased morbidity and mortality, longer hospital stays, and increased utilization of health services. Prevention and early recognition are especially important in delirium management. Factors known to increase the risk of delirium include cognitive, visual or hearing impairments, immobility, dehydration, and sleep
Malnourishment is a significant issue seen with chronic alcohol use, resulting in deficiencies in vitamins A, B, and C, magnesium, folic acid, carnitine, selenium, zinc, antioxidants, and essential fatty acids. Moderate alcohol use has been associated with a higher risk of certain types of cancer, including cancers of the esophagus, larynx, mouth, liver, colon, and breast. Alcohol use is also associated with a higher risk of developing diabetes or acquiring HIV, and complicates disease state management due to the effects on medication adherence. 208 Alcohol interacts with a number of prescription medications, including opioids, anticoagulants, anxiolytics, sedatives, and anticonvulsants. Elderly patients and patients with polypharmacy are at a particularly high risk of experiencing adverse effects from medication-alcohol interactions. 208 Unhealthy alcohol use can also cause a number of social and mental health consequences. Depression is highly correlated with alcohol use disorders. Accidents such as falls, burns, and firearm injuries are more common among heavy drinkers, as is unsafe sex, intimate partner violence, homicide, and suicide. 208 Alcoholic liver disease Alcoholic liver disease covers a spectrum of liver disorders, beginning with steatosis, or fat accumulation in the liver, progressing to hepatitis, or inflammation of the liver cells, and ending with cirrhosis, or irreversible damage to the liver. 209 Signs and symptoms of liver disease can include: 171 • Edema • Jaundice • Dark colored urine • Itchy skin • Pale, bloody, or tar-colored stool • Chronic fatigue • Confusion • Nausea or vomiting Heavy alcohol users can present with alcoholic liver disease between 40 and 50 years of age. Liver disease can be progressive; between 10 to 20% of patients with alcoholic hepatitis progress to cirrhosis each year. The management of alcoholic liver disease can vary depending on the extent of disease. Alcohol cessation is highly recommended, and patients may also require laboratory or diagnostic studies, nutritional support, regular screening for liver cancer, and treatment of complications or co-existing infections. A number of complications can arise from alcoholic liver disease, including variceal bleeding, ascites, peritonitis, renal failure, and encephalopathy. 209 Pancreatitis Long term alcohol use causes between 17 and 25% of cases of acute pancreatitis worldwide. This inflammatory condition affecting the pancreas causes acute abdominal pain, nausea, vomiting, anorexia, and high lipase levels. Severe cases can present with acute respiratory distress syndrome or shock.
Acute pancreatitis often requires hospitalization and management with IV fluids, electrolyte replacement, analgesics and antiemetics. 210 Between 40 to 70% of cases of chronic pancreatitis are caused by chronic alcohol use. Patients who experience recurrent cases of acute pancreatitis are significantly more likely to progress to chronic pancreatitis, in which the inflammation of the pancreas worsens over time, leads to permanent damage, and increases the patient’s risk of pancreatic cancer. Chronic pancreatitis can cause the pancreas to work less efficiently, leading to poor fat absorption, steatorrhea, and diabetes. Complications of chronic pancreatitis can be local effects on the pancreas, such as necrosis and pseudocysts, as well as systemic complications such as sepsis, pleural effusion, bacteremia and shock. 210 Screening/Assessment Alcohol use should be assessed in patients presenting with any of the above comorbidities. When assessing a patient with suspected unhealthy alcohol use, patients should be asked about the following: 211 • Past and current use of alcohol and any prior treatment. • Family history of issues related to alcohol and treatment. • Details on the quantity and frequency of use. • Symptoms and behaviors associated with the following: ° Alcohol use disorder criteria. ° Medical comorbidities. ° Behavioral complications. ° Psychiatric complications. ° Use of other substances. A physical examination should be conducted to assess for features of unhealthy alcohol use. Patients may come to appointments smelling of alcohol or actively under the influence of alcohol, as noted by slurred speech, incoordination, dehydration, flushing, confusion, aggression, nausea, or vomiting. Signs of alcohol withdrawal include tremor, agitation, hypertension, diaphoresis, or clouded senses. Patients with advanced liver disease may present with hepatic enlargement, splenic enlargement, ascites, or yellowing skin or eyes: 211 Laboratory evaluation can test for abnormalities related to heavy, repeated alcohol use or liver disease. Liver enzymes, including aspartate aminotransferase (AST), alanine aminotransferase (ALT), bilirubin and albumin, can assess for liver damage. Hemoglobin and complete blood count can determine the presence of anemia or blood dyscrasias associated with heavy alcohol use or liver disease. 211 Patients with suspected alcohol withdrawal should have a similar assessment, with a focus on assessing recent or current withdrawal symptoms, history of prior withdrawal, and urine drug testing to rule out other substance use.
deprivation. 171 Complications
The unhealthy use of alcohol can cause a number of medical and psychiatric complications, with higher use resulting in more profound effects. Health conditions associated with excessive alcohol
use include: 208 • Cirrhosis • Hypertension • Stroke
• Cardiomyopathy • Hypogonadism • Gastrointestinal effects such as GI bleeding, gastritis and GERD • Osteoporosis
• Sexual dysfunction • Chronic pancreatitis • Brain atrophy • Seizures • Arrhythmias
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