These triggers can create a psychological and physiological response in the brain, leading to a strong urge to use alcohol. The prefrontal cortex, responsible for executive function, is compromised in alcohol use disorder. 133 Alcohol Intoxication Alcohol intoxication usually develops over minutes to hours and lasts about several hours. The first episode of alcohol intoxication most commonly occurs in the mid-teens, but alcohol use disorder is not typically identified in late teens or early 20s. The essential feature of alcohol intoxication is the presence of behavioral or psychological changes, including inappropriate sexual or aggressive behavior, mood lability, impaired judgment, and levels of incoordination that may interfere with the performance of usual activities. The degree of intoxication increases with the blood alcohol concentration, especially when combined with other sedation-producing substances. 4 Table 1. Blooad Alcohol Concentrations (BAC) with Impairment 20-30 mg/dL Slowed motor impairment with decreased thinking ability 30-80 mg/dL Increased motor and cognitive problems 80-200 mg/dL Incoordination and judgment errors with deterioration in cognition 200-300 mg/ dL Nystagmus, slurred speech, and blackouts >300 mg/dL Impaired vital signs and possible death If an individual lacks significant impairment at 150 mg/dL, pharmacodynamic tolerance may be present. 23 However, an individual’s history of regular exposure to alcohol dictates the behavior that follows its consumption since the human body and the central nervous system can develop tremendous tolerance to ethanol. Mental and physical dysfunctions from ethanol, in an alcohol- tolerant individual, do not consistently correlate with ethanol levels traditionally used to define intoxication, or even lethality, in a nontolerant subject. 22 Alcohol Withdrawal Alcohol withdrawal can occur with anyone with alcohol use disorder and symptoms can range from mild to severe and occasionally life threatening. Minor symptoms include anxiety, tremor, diaphoresis, palpitations, nausea and vomiting. The symptoms can be progressive and severe, eventually leading to seizures and autonomic hyperactivity. The classic sign of alcohol withdrawal is tremulousness. 23 Alcohol withdrawal seizures typically occur within 6-48 hours after cessation of drinking in a habituated alcohol drinker and occur in 10-30 percent of patients in alcohol withdrawal. Alcohol withdrawal can produce generalized tonic clonic seizures, but status epilepticus is rare. 23
The estimated progression of alcohol withdrawal symptoms is presented in Table 2. 23 Evaluation of the severity of withdrawal includes physical examination and the use of the CIWA score. The Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) scale has 10 items, each evaluated independently and then aggregated to yield a score correlating with severity of alcohol withdrawal. 23 The CIWA-AR score requires evaluation of each symptom rated on a 0-7 score for all except evaluation of orientation and clouding of sensorium, which is on a 0-4 score. Maximum score is 67:
Hospital protocols vary, but admission to monitored or intensive care settings is warranted for significant withdrawal symptoms. Complications of Chronic Alcohol Use Chronic alcohol use is associated with many conditions. Alcohol is characterized as a Group 1 carcinogen along with tobacco, radiation, and asbestos. It is associated with bowel and breast cancer and although previously thought to be safe in light and moderate consumption, the World Health Organization (WHO) has now published a statement in The Lancet Public Health that when it comes to alcohol consumption, there is no safe amount of alcohol that does not affect health. 27 Chronic alcohol use is commonly associated with many health issues as follows: • Gastrointestinal: hepatic steatosis, hepatitis and cirrhosis, gastritis, and ulcer disease leading to GI bleeding and pancreatitis • Cardiac: cardiomyopathies, hypertension, heart failure, and arrhythmias leading to stroke • Metabolic: electrolyte derangements, including hypoglycemia and hyponatremia and hypomagnesemia, thrombocytopenia, osteopenia, folate and thiamine deficiencies • Genitourinary: chronic alcohol use contributes to erectile dysfunction and dysfunctional uterine bleeding • Immunologic: increased risk of infection through effects on lymphocyte response • Long term alcohol use associated with increased frequency of many malignancies • Psychologic: depression and anxiety • Increased risk of injury due to dangerous behavior Wernicke-Korsakoff syndrome (WKS) is one of the best-known neurologic complications of thiamine (vitamin B1) deficiency that is frequently associated with long-term alcohol use. Thiamine is involved in the conduction of axon potential and synaptic transmission. WKS refers to two different syndromes, each representing a different stage of the disease. Wernicke encephalopathy (WE) is an acute syndrome requiring emergent treatment to prevent death and neurologic morbidity. Korsakoff syndrome (KS) refers to a chronic neurologic condition that usually occurs as a consequence of WE. Wernicke encephalopathy (alcoholic encephalopathy) is characterized by ataxic gait, vestibular dysfunction, confusion, horizontal nystagmus, lateral orbital palsy, and gaze palsy. WE is reversible with acute treatment including replacement of thiamine and other deficient vitamins such as folic acid.
• Agitation (0-7) • Anxiety (0-7)
• Auditory disturbances (0-7) • Clouding of sensorium (0-4) • Headache (0-7)
• Nausea/vomiting (0-7) • Paroxysmal sweats (0-7) • Tactile disturbances (0-7) • Tremor (0-7) • Visual disturbances (0-7) Scores correlate to general level of withdrawal as follows:
Score
Withdrawal Level
≤8
Absent or minimal withdrawal Mild to moderate withdrawal
9-19 ≥20
Severe withdrawal
Delirium Withdrawal delirium, also commonly referred to delirium tremens or “DTs,” is the most dangerous withdrawal syndrome associated with alcohol. This spectrum of symptoms that includes confusion, disorientation, hallucinations, and delusions along with autonomic hyperactivity, anxiety, and fluctuating levels of psychomotor activity has a modern mortality of under 5% if treated as opposed to mortality rates greater than 25% early in the 20th century. 24 Withdrawal delirium typically begins between 72 and 96 hours after the patient’s last drink and has been reported to occur in 1 to 4 percent of patients hospitalized for alcohol withdrawal. 25 Delirium tremens should be considered a medical emergency and can be fatal if not managed aggressively. The main objectives of treatment for alcohol withdrawal are controlling agitation, lowering seizure risk, and reducing morbidity and mortality. Benzodiazepines such as diazepam and lorazepam are first-line treatment for all alcohol withdrawals. Barbiturates and propofol can be used for those patients who are refractory to benzodiazepines. 26
Table 2. Alcohol Withdrawal Progression
Progression
Symptoms
Time to Presentation
Mild
Tremulousness
6-8 hours 8-12 hours 12-24 hours
Moderate
Perceptual disturbances
Severe
Seizures
Life threatening
Delirium tremens
Within 72 hours
25
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