What are the symptoms and treatment options for alcoholism?

Symptoms and Treatment of Alcoholism

Alcoholism is diagnosed when a person exhibits at least 2 of 11 specific symptoms defined in diagnostic criteria, with severity ranging from mild (2-3 symptoms) to moderate (4-5 symptoms) to severe (6+ symptoms). 1

Diagnostic Symptoms of Alcohol Use Disorder

The American Association for the Study of Liver Diseases identifies the following diagnostic criteria:

• Alcohol consumption in larger amounts or over longer periods than intended 1
• Persistent desire or unsuccessful efforts to cut down or control alcohol use 1
• Significant time spent obtaining, using, or recovering from alcohol effects 1
• Craving or strong urge to use alcohol 1
• Recurrent alcohol use resulting in failure to fulfill major role obligations 1
• Continued use despite persistent social or interpersonal problems caused by alcohol 1
• Important activities given up or reduced because of alcohol use 1
• Recurrent alcohol use in physically hazardous situations 1
• Continued use despite knowledge of physical or psychological problems caused by alcohol 1
• Tolerance (needing increased amounts for effect or diminished effect with same amount) 1
• Withdrawal symptoms or taking alcohol to avoid withdrawal 1

Physical and Laboratory Signs of Alcoholism

• Elevated liver enzymes, particularly gamma-glutamyl transferase (GGT) with greater sensitivity than AST 1
• Carbohydrate-deficient transferrin (CDT), which has a half-life of 2-3 weeks 1
• Macrocytic anemia 1
• Signs of malnutrition and vitamin deficiencies, particularly B vitamins 1

Alcohol Withdrawal Syndrome

Alcohol withdrawal syndrome (AWS) is a severe medical condition affecting alcohol-dependent patients who suddenly discontinue or decrease alcohol consumption:

• Light to moderate AWS develops within 6-24 hours after the last drink 1
• Symptoms include increased blood pressure, increased pulse rate, tremors, hyperreflexia, irritability, anxiety, headache, nausea, and vomiting 1
• Severe forms can progress to delirium tremens, seizures, coma, cardiac arrest, and death 1
• Mortality rate for delirium tremens is under 3% with appropriate treatment 2

Treatment Approaches for Alcoholism

1. Screening and Assessment

• The US Preventive Services Task Force recommends screening for unhealthy alcohol use in primary care settings for adults 18 years or older, including pregnant women 1
• Biomarkers should be used as an aid to diagnosis, to support recovery, and as catalysts for discussion with the patient 1
• Laboratory tests should be combined with physical exam and clinical interview 1

2. Management of Alcohol Withdrawal

• Benzodiazepines are the gold standard treatment for AWS due to their efficacy in reducing withdrawal symptoms and the risk of seizures/delirium tremens 1
• Long-acting benzodiazepines (diazepam, chlordiazepoxide) provide more protection against seizures and delirium 1
• Short and intermediate-acting benzodiazepines (lorazepam, oxazepam) are safer in elderly patients and those with hepatic dysfunction 1
• Thiamine supplementation (100-300 mg/day) is essential to prevent Wernicke encephalopathy 1
• Inpatient treatment is recommended for cases with serious complications such as alcohol withdrawal delirium or seizures 1

3. Pharmacotherapy for Maintaining Abstinence

• Naltrexone (50 mg once daily) has been shown to reduce relapse rates (21% vs 41%) and alcohol craving compared to placebo 3
• Naltrexone should be avoided in patients with severe liver disease due to potential hepatotoxicity 3
• Acamprosate is effective in maintaining abstinence, typically given for 3-6 months 1
• Baclofen has shown promise in patients with liver cirrhosis by reducing alcohol craving 1
• Disulfiram should be avoided in patients with severe alcoholic liver disease 1

4. Psychosocial Interventions

• Brief behavioral counseling interventions help reduce unhealthy alcohol use 1
• Individual support and effective communication reduce the risk of severe withdrawal syndrome 2
• Patients need close personal support, communication, and a reassuring environment 2
• Cognitive-behavioral therapies help avoid relapses 4

Common Pitfalls and Caveats

• Biomarkers alone are inadequate to establish alcohol use in alcoholic liver disease 1
• Patients must be opioid-free for 7-10 days before starting naltrexone to avoid precipitated withdrawal 3
• Alcoholics have high psychiatric comorbidity including anxiety disorders, affective disorders, and schizophrenia 1
• Alcoholics have a higher risk of developing other addictions, including nicotine, requiring more intensive support 1
• Depression, suicidal ideation, and suicide attempts have been reported in all treatment groups (naltrexone and placebo) 3

Early identification and aggressive treatment of alcohol withdrawal syndrome are crucial for improving outcomes and reducing mortality in patients with alcoholism 5, 6.