Background
The American Psychiatric Associations DSM-IV recognizes two distinct primary
disorders of alcohol use: alcohol abuse and alcohol dependence. Together, their lifetime
prevalence in the general population is 13.6 percent, according to the National Institute
of Mental Health (NIMH) Epidemiologic Catchment Area study. Alcohol use disorders are many
times more common in males than in females (4:1 in the U.S.), and their onset is usually
between ages 16 and 30. Both genetic and environmental factors contribute to their
etiology. Alcohol use disorders have traditionally been significant problems in the Navy,
though their impact on readiness has declined over recent decades.
Definitions
It is crucial for the GMO to be able to distinguish nonpathological
alcohol use from alcohol abuse and alcohol dependence. Alcohol abuse is defined
simply as a maladaptive pattern of alcohol use leading to clinically significant
impairment or distress. The alcohol-related impairment or distress may be evident in
recurrent failures to fulfill obligations at work, school, or home, or in recurrent health
or legal problems due to alcohol use. Typically, individuals with alcohol abuse continue
to use alcohol despite these adverse consequences.
Alcohol dependence is defined as alcohol abuse
with the additional feature of physiological and psychosocial evidence of addiction. The
symptoms of alcohol dependence include:
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Tolerance (needing increasing amounts to obtain desired effect)
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Withdrawal (irritability, insomnia, malaise, tachycardia, tremors, nausea, vomiting,
and/or tactile hallucinations beginning 24-48 hours after the last drink)
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Unsuccessful attempts to cut down or stop
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Devoting more time to activities necessary for obtaining alcohol
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Giving up other activities because of alcohol
Diagnosis
Once a patient is known to have the above symptoms, the diagnosis of an alcohol
abuse disorder is easier. However, one diagnostic problem is obtaining accurate
information from the patient about their alcohol use, particularly since denial is a
cardinal feature of all alcohol use disorders. The more blatantly harmful the consequences
of someones drinking, the more tenacious in denial they must be if they are to keep
using alcohol. The GMO must continually maintain a high index of suspicion, particularly
for patients who present with unexplained accidents or injuries, repeated lateness or
absences from work, other personality changes, or a history of gastritis, pancreatitis, or
hepatomegaly.
A useful screening tool for alcohol use disorders is the CAGE questionnaire, consisting
of the following questions:
C: Have you ever felt you ought to Cut down on your drinking?
A: Have people ever Annoyed you by criticizing your drinking?
G: Have you ever felt bad or Guilty about your drinking?
E: Have you ever had a morning Eye opener to steady your nerves or get rid of a
hangover?
Physical Signs and
Laboratory Studies
Note the absence or presence of an alcohol odor on the breath, ataxia, red nose or
palms, spider nevi, jaundice, poor dental care, abdominal tenderness, signs of portal
hypertension, or loss of peripheral sensation or motor power. In addition to the blood
alcohol level (>200 mg/dl is suggestive), macrocytosis, elevated transaminases
(especially SGGT), and elevated uric acid and triglycerides may be found (but usually only
in severe and chronic cases).
Treatment
If an alcoholic patient presents in coma, protect the airway and give the standard
oxygen, thiamine, glucose, and Narcan. Consider gastric lavage if other drug ingestion is
suspected. For patients who are abusive or violent, use physical or chemical restraints as
necessary. Significant alcohol withdrawal symptoms should be treated with thiamine and a
benzodiazepine. Admit patients who are dangerously intoxicated, those with a history of
serious withdrawal symptoms in the past, those with unstable medical complications, and
those who are suicidal.
Further evaluation and aftercare
Once medically stable, all active duty patients suspected of having an alcohol use
disorder should be referred to their command DAPA or CAAC for further evaluation.
Depending on the nature and severity of the disorder, the member may then be afforded
treatment ranging from brief educational classes (Level 1) to domiciliary rehabilitation
(Level 3). Abstinence from alcohol use and attendance at AA meetings will be recommended.
Refusal to participate in treatment for an alcohol use disorder is grounds for
administrative separation.
Final notes
As the service members primary physician, you retain an important
role throughout his or her evaluation, treatment, and aftercare. Maintain active liaison
between the members command and treatment facilities. Steadfastly encourage
abstinence and compliance with treatment recommendations, but dont yield to
temptations to be judgmental. Remember that alcohol use disorders are chronic and that
recovery is a long and difficult road.
Reference
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The American Psychiatric Press Synopsis of Psychiatry
, edited by Robert Hales and
Stuart
Yudofsky, published by American Psychiatric Press, Washington, DC, 1996.
Revised by CAPT William P. Nash, MC, USN, Psychiatry Specialty Leader, Naval
Medical Center San Diego, (1998).