Alcohol

Standard Drink

Standard Drink Sizes (Adapted from: The Chief Public Health Officer's Report on the State of Public Health in Canada, 2014: Public Health in the Future Figure 1

Quantifying alcohol use can be hard, given the wide range of alcoholic beverages, shapes, and sizes. A standard drink (SD) is a unit that is used to quantify alcohol intake in a systematic way (however, a standard drink varies from country to country). In Canada, a standard drink is any drink that contains 13.6 grams of pure alcohol or the equivalent of 0.6 ounces of 100% alcohol.

Different alcoholic beverages have different concentrations of alcohol. For example, most beers contain 5% alcohol; wines contain 12 to 13% alcohol; and spirits can contain 40% alcohol or more. In addition, different shapes and sizes of containers will contain different volume of alcoholic drinks (See Figure 1).

AUDIT

The Alcohol Use Disorders Identification Test (AUDIT) (AUDIT) is a 10-item self-report questionnaire. It asks questions about past-year quantity and frequency of drinking, consequences of drinking (e.g., blackouts), and questions similar to the CAGE. It may be more accurate than the CAGE in identifying alcohol use disorders. Also, unlike the CAGE, it can help distinguish alcohol dependence from hazardous or at-risk drinking.

The diagnostic criteria in the DSM-5 for alcohol use disorder is as follows:[1]

Criterion A

A problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least 2 of the following, occurring within a 12-month period:

  1. Alcohol is often taken in larger amounts or over a longer period than was intended.
  2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use.
  3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects.
  4. Craving, or a strong desire or urge to use alcohol.
  5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home.
  6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol.
  7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use.
  8. Recurrent alcohol use in situations in which it is physically hazardous.
  9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol.
  10. Tolerance, as defined by either of the following: (A) a need for markedly increased amounts of alcohol to achieve intoxication or desired effect, or (B) a markedly diminished effect with continued use of the same amount of alcohol.
  11. Withdrawal, as manifested by either of the following: (A) the characteristic withdrawal syndrome for alcohol (refer to Criteria A and B of the criteria set for alcohol withdrawal), or (B) alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid withdrawal symptoms.
Specifier
  • In early remission: After full criteria for alcohol use disorder were previously met, none of the criteria for alcohol use disorder have been met for at least 3 months but for less than 12 months (with the exception that Criterion A4, “Craving, or a strong desire or urge to use alcohol,” may be met).
  • In sustained remission: After full criteria for alcohol use disorder were previously met, none of the criteria for alcohol use disorder have been met at any time during a period of 12 months or longer (with the exception that Criterion A4, “Craving, or a strong desire or urge to use alcohol,” may be met).
  • In a controlled environment: This additional specifier is used if the individual is in an environment where access to alcohol is restricted.
  • Alcohol and benzodiazepine withdrawal are treated the same way. Alcohol and benzodiazepine withdrawal are the two substance withdrawals that can also kill patients! Withdrawal seizures can be the initial clinical presentation.
  • RCTs have clearly shown that to stop alcohol withdrawal seizures you use benzodiazepines; anti-epileptics do not work.

CIWA

The Clinical Institue Withdrawal Assessment (CIWA) was developed in Toronto in the 1980s.[2] It is considered the gold-standard for measurement of alcohol withdrawal symptoms.

Outpatient

Outpatient Alcohol Withdrawal Management

A diazepam taper with thiamine supplementation can be used:

  1. Diazepam 10mg POD QID x 3 days, 12 tabs total
  2. Diazepam 10mg PO BID x 3 days, 6 tabs total
  3. Thiamine 300mg PO daily x 1 month

Inpatient

Inpatient Alcohol Withdrawal Management

Uncomplicated withdrawal Complicated withdrawal
Definition No history of siezures or delirium tremens A history of withdrawal seizures, delirium tremens, pregnancy or geriatric
Management Diazepam 20mg PO q1-2h until CIWA < 10
OR
Lorazepam 2mg q1-2h until CIWA < 10
Load with diazepam 20mg q1h x 3 = 60mg
Lorazepam 2mg q1h x 3 = 60mg total to start
Then administer CIWA based on symptoms

Drug-drug interactions

  • If patients are on mood stabilizer like lithium or valproic acid, ensure that levels are drawn
    • Lithium may increase due to diuresis from alcohol, and lithium toxicity can cause tremulousness and nausea (mimicking alcohol withdrawal)
    • Valproic acid combined with with alcohol use increases risk of liver damage. This can also increase valproic acid levels due to decreased metabolism
  • May want to switch patients to lorazepam instead if blood work shows elevated liver enzymes
    • Lorazepam is not conjugated in the liver like diazepam

Alcohol Dependence Treatment

Efficacy: Naltrexone > Acamprosate > Gabapentin > Disulfram

References

1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013.