An Introduction to
Diagnosis and
Treatment of
Alcoholism
Marc A. Schuckit, M.D.
Copyright Alcohol Medical Scholars Program
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Alcohol Prevalence
90% Ever drank
60% Current drinkers
>40% Temporary problems
10-20% Abuse
3-10% Dependence
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YEARLY COSTS IN US
$300 Billion Overall
$71 Billion Direct Costs
22,000 Deaths + 2,000,000 Injuries
4,600,000 Damaged Vehicles
15% - 25% Healthcare Budget
90% of Liver Disease
72% of Pancreatitis
41% of Seizure Disorders
13% Breast Cancers
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3
DSM-IV Dependence
1. Tolerance*
2. Withdrawal*
3. Larger amounts/longer period than intended
4. Inability to, or persistent desire to, cut down
or control
5. A great deal of time spent obtaining, using, or
recovering
6. Important activities given up or reduced
7. Use despite problems caused or exacerbated by use
*Dx: “with Physiological Dependence”
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DSM-IV Abuse
1. Failure to fulfill major role obligations
2. Use in hazardous situations
3. Legal Problems
4. Use despite problems
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5
Alcoholism Natural History
Event
1st drink
1st drunk
1st problem
1st dependence
Death
Age
13
15
18
25-40
60
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6
Alcoholism Course
•Fluctuating:
controlled use
problems
abstinence
•20% spontaneous remission
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7
Dual Diagnosis
 2/3 Have Psych. Dx
 1/3 Axis I
 Most are Substance Induced Disorders
 Schiz., MDD, ASPD Risk
 Use a Timeline
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TIMELINE
B
40
 Age Onset Dependence
 Ages 3+ mo. Abstinence
 Ages of Major Disorder
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Ask All Patients
About Problems In:
•Relationships
•School or job
•Accidents
•Arrests
•Health
THEN tie in substances
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10
State Markers •GGT > 30
•MCV > 91
•CDT < 20
•+UA; Lipids; etc.
•Questionnaires:
MAST
CAGE
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POSSIBLE BRIEF SELF-ADMINISTERED
QUESTIONNAIRES FOR SCREENING
ALCOHOL PROBLEMS
1. 4 Item CAGE
2. 5 Item TWEAK
3. 25 Item Michigan Alcohol
Screening Test (MAST)
4. 10 Item Alcohol Use Disorders
Identification Test (AUDIT)
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Stages of Treatment
 Identification
 Detoxification
 Physical exam and history
 Vitamins
 Reassurance
 + Benzodiazepines
 Rehabilitation
 Enhance motivation
 Help readjust to life
 Relapse Prevention
 + Medications
 Aftercare
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Withdrawal
Autonomic dysfunction - Insomnia Anxiety
* Begin 8+ hours
* Diminish at day 5
* Peak at day 2
* Disappear 3 - 6 months
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Treatment of Withdrawal
Physical examination
Supports
Vitamins
CNS depressants
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Rehabilitation

Increase motivation

Help rebuild life
Relapse

Prevention
+/- medications
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16
Alcohol Rehab
? Naltrexone
? Acamprosate
? Disulfiram
? SSRI
Not:
? Buspirone
LI, Anti-depressants,
Other
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17
GENETICS
 Familial
 MZ > DZ
 4x Risk, Even if Adopted
 LR Predicts Risk
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