Alcoholism Study Guide

📖 Core Concepts Alcohol Use Disorder (AUD) – chronic, maladaptive alcohol use despite harmful consequences; diagnosed via DSM‑5 (AUD) or ICD‑11 (alcohol dependence). Binge Drinking – ≥5 drinks/occasion for men, ≥4 for women; a major gateway to dependence. Withdrawal – neuroadaptation of GABA\(A\) receptors leads to hyper‑excitability when BAC falls; can be life‑threatening. CIWA‑Ar – standardized scale (0–67) that quantifies withdrawal severity and guides medication dosing. Pharmacologic Relapse‑Prevention – Acamprosate (glutamate antagonist), Naltrexone (opioid antagonist), Disulfiram (acetaldehyde‑dehydrogenase inhibitor). Psychosocial Relapse‑Prevention – CBT, Motivational Interviewing, 12‑step/facilitation, harm‑reduction vs. abstinence models. Risk Factors – family history (3–4× risk), ADH1B/ALDH2 variants, early initiation, high stress, co‑use of other substances. Gender Differences – women reach higher BAC per drink, develop liver disease & cardiovascular complications faster, and face greater stigma. --- 📌 Must Remember Diagnostic threshold: ≥2 of 11 DSM‑5 criteria within 12 months = AUD (mild 2‑3, moderate 4‑5, severe ≥6). Screening cut‑offs: CAGE ≥2; AUDIT ≥8 (≥4 for women); PAT positive → brief intervention. BAC effect bands: 0.03–0.12 % → euphoria, impaired judgment. 0.18–0.30 % → confusion, vomiting. ≥0.35 % → coma, possible death. First‑line withdrawal meds: short‑acting benzodiazepines (lorazepam, oxazepam). Acamprosate contraindications: decompensated cirrhosis, severe renal impairment. Naltrexone contraindications: advanced liver disease, current opioid use. Disulfiram contraindications: severe liver disease; limited efficacy evidence. Kindling: each withdrawal episode → higher seizure/DT risk. Mortality impact: AUD reduces life expectancy ≈10 years; cardiovascular disease is leading cause of death. --- 🔄 Key Processes Alcohol Withdrawal Management (Symptom‑Triggered) Assess CIWA‑Ar every 1–2 h. If score ≥ 8 → give benzodiazepine (dose based on severity). Re‑assess; taper as scores fall below threshold. DSM‑5 Diagnosis Workflow Screen (CAGE/AUDIT). → Positive → full clinical interview. → Count criteria → assign severity. Pharmacologic Relapse‑Prevention Initiation After detoxification & medical clearance. Choose: Acamprosate (abstinence support) vs. Naltrexone (craving reduction) vs. Disulfiram (deterrent). Monitor liver/kidney labs; adjust dose. Risk‑Factor Evaluation Obtain family history, age of first drink, genetic testing (if available for ADH1B/ALDH2). Assess stressors, co‑substance use, psychosocial environment. --- 🔍 Key Comparisons Benzodiazepine vs Phenobarbital – Benzos first‑line; phenobarbital added when benzo dose insufficient or refractory. Acamprosate vs Naltrexone – Acamprosate → maintains abstinence (glutamate modulator); Naltrexone → reduces craving/reward (opioid antagonist). Abstinence Model vs Harm‑Reduction – Abstinence: zero alcohol, 12‑step focus; Harm‑reduction: controlled drinking goals, moderation‑management programs. Short‑acting vs Long‑acting Benzodiazepines – Short‑acting (lorazepam) preferred in liver disease; long‑acting (diazepam) higher accumulation risk. --- ⚠️ Common Misunderstandings “One drink is safe” – No level of alcohol is completely risk‑free; even low‑level use raises cancer risk. “Disulfiram cures alcoholism” – It only deters drinking while taken; adherence is poor and evidence of efficacy is limited. “Women need less medication” – Dosing is generally the same; however, women are more vulnerable to liver toxicity and should be monitored closely. “Withdrawal is always mild” – Severe withdrawal (DTs, seizures) occurs in 10 % and can be fatal without treatment. --- 🧠 Mental Models / Intuition “Push‑Pull” GABA/Glutamate model: Chronic alcohol = “push” (enhanced GABA inhibition). Withdrawal = “pull” (unopposed glutamate → excitability). “Risk‑Factor Pyramid”: Genetics & early initiation at the base → environmental stressors → binge patterns → dependence. “Screen‑Treat‑Prevent” loop: Screening → brief intervention → treatment (detox + meds) → long‑term prevention (psychosocial support, policy). --- 🚩 Exceptions & Edge Cases ALDH2 deficiency: Severe flushing after small amounts; protective against dependence but increases cancer risk if drinking continues. Pregnant women: Any alcohol intake risks fetal alcohol spectrum disorder → complete abstinence required. Severe renal impairment: Acamprosate contraindicated; consider naltrexone (if liver OK). Co‑dependence with benzodiazepines: Requires simultaneous tapering of both agents to avoid cross‑withdrawal seizures. --- 📍 When to Use Which Mild‑moderate withdrawal, stable home: Outpatient benzodiazepine protocol + CIWA‑Ar monitoring. Severe withdrawal, DT risk, comorbid medical issues: Inpatient care, possible phenobarbital adjunct, continuous vitals. Patient motivated for abstinence, no liver disease: Acamprosate after detox. Patient with strong craving, no opioid use, mild‑moderate liver disease: Oral or injectable Naltrexone. Highly motivated, reliable adherence, wants deterrent effect: Disulfiram (with liver monitoring). Co‑occurring anxiety/depression: Integrated CBT + pharmacotherapy; avoid long‑term benzodiazepines. --- 👀 Patterns to Recognize Binge → rapid escalation – Look for ≥5/4 drinks episodes; often precedes dependence. Kindling trajectory – Each withdrawal episode > more severe symptoms → prioritize early, effective detox. Gender‑specific labs: Women often have higher GGT/PEth for same intake → consider in biomarker interpretation. Polysubstance use – Cannabis, tobacco, or illicit drugs frequently co‑occur; screen for them. --- 🗂️ Exam Traps “Alcohol reduces mortality” – Distractor; AUD actually shortens life by 10 years. “Only liver disease matters in AUD” – Wrong; cardiovascular, cancer, neurocognitive, and psychiatric effects are equally high‑yield. “CAGE ≥ 1 is diagnostic” – Only ≥2 suggests further evaluation. “Long‑acting benzodiazepines are safer” – In liver disease short‑acting agents are preferred. “Disulfiram is first‑line for relapse prevention” – Not evidence‑based; naltrexone or acamprosate have stronger data. ---