Alcohol Dependence
Trapped in the Bottle
Jake had always been the life of the party. A drink after work turned into two, then three. Over time, he needed more to feel the same buzz, and soon, he wasn’t drinking for fun—he was drinking to function.
Mornings became a battle against shaking hands and splitting headaches, eased only by another sip of whiskey. His boss noticed the missed deadlines, his friends noticed the slurred words, and his family noticed the man they once knew slipping away.
One night, staring at his reflection in an empty bottle, Jake realized: he wasn’t in control anymore—alcohol was.
Definition
- Alcohol Dependence is a chronic, relapsing condition characterised by compulsive alcohol consumption, loss of control over drinking, and continued use despite negative consequences.
Ranges from hazardous drinking (excessive intake without dependence) to alcohol dependence (tolerance, withdrawal, and cravings)
Causes & Risk Factors
Pathophysiology
- Dopamine Reward System Dysfunction → Increased Dopamine Release in the Mesolimbic Pathway (Reinforces Alcohol Consumption).
- GABA & Glutamate Imbalance → Alcohol Enhances GABA (Sedative Effects) and Inhibits Glutamate (Excitatory Neurotransmission), Leading to Tolerance & Dependence.
Chronic Neuroadaptation → Long-Term Use Leads to Withdrawal Symptoms When Alcohol is Absent.
Risk Factors for Alcohol Dependence
Mnemonic for Risk Factors of Alcohol Dependence: “GAMES-H”
Each letter represents a key risk factor:
- G → Genetics (50% heritability, family history of alcohol dependence)
- A → Adverse Childhood Experiences (ACEs) (Trauma, neglect, parental alcoholism)
- M → Mental Health Disorders (Depression, anxiety, PTSD, bipolar disorder)
- E → Environmental & Social Norms (Binge drinking culture, peer pressure)
- S → Stress (High-Stress Lifestyle) (Work, relationships, personal struggles)
- H → Health Conditions (Chronic pain, self-medicating with alcohol)
Quick Recall Phrase:
“Playing GAMES-H with alcohol can lead to dependence.”
This should help recall the main risk factors for alcohol dependence easily! 🍻🚫
🔹 Genetics, early trauma, and environmental influences contribute to AUD.
Clinical Features
Symptoms of Alcohol Dependence (DSM-5 Criteria)
- Diagnosis Requires ≥2 Symptoms Within a 12-Month Period.
|
Category |
Common Symptoms |
|
Loss of Control |
Drinking More or Longer Than Intended. |
|
Cravings |
Strong Desire or Urge to Drink. |
|
Tolerance |
Needing More Alcohol to Achieve the Same Effect. |
|
Withdrawal Symptoms |
Tremors, Sweating, Nausea, Anxiety on Stopping. |
|
Neglect of Responsibilities |
Work, Family, or Social Obligations Affected. |
|
Continued Use Despite Harm |
Drinking Despite Physical, Psychological, or Social Consequences. |
Signs on Examination
|
Feature |
Description |
|
Tremors & Autonomic Hyperactivity |
Sweating, Tachycardia, Anxiety (Alcohol Withdrawal). |
|
Hepatomegaly |
Fatty Liver, Alcoholic Hepatitis. |
|
Jaundice & Ascites |
Liver Cirrhosis (Advanced Disease). |
|
Peripheral Neuropathy |
Numbness, Tingling in Hands & Feet. |
|
Cognitive Impairment |
Memory Deficits, Confusion (Wernicke-Korsakoff Syndrome). |
🔹 Alcohol affects multiple organ systems, leading to neurological, hepatic, and cardiovascular complications.
Referral Criteria (NICE Guidelines)
Urgent Referral (If Severe Symptoms or Risk to Self/Others)
- Acute Alcohol Withdrawal With Risk of Seizures or Delirium Tremens (DTs).
- Severe Alcohol Intoxication (Unconscious, Respiratory Depression).
- Suicidal Ideation or Self-Harm Related to Alcohol Use.
- Wernicke’s Encephalopathy (Confusion, Ataxia, Ophthalmoplegia).
Routine Referral (If Symptoms Persist or Affect Functioning)
- Chronic Alcohol Dependence With Physical or Psychological Harm.
- Recurrent Relapses Despite Previous Treatment.
- Comorbid Mental Health Disorders (Dual Diagnosis).
- Social Vulnerability (Homelessness, Family Breakdown).
🔹 Severe withdrawal or intoxication requires emergency care, while chronic dependence needs addiction services.
Diagnosis & Screening Tools
Clinical Diagnosis (DSM-5 Criteria for Alcohol Dependence)
|
Criterion |
Description |
|
Compulsive Drinking |
Strong Urge to Drink Despite Consequences. |
|
Loss of Control |
Drinking More Than Intended, Unsuccessful Attempts to Quit. |
|
Tolerance & Withdrawal |
Higher Doses Needed, Symptoms on Stopping. |
|
Functional Impairment |
Affects Work, Relationships, Health. |
Screening Tools
|
Tool |
Purpose |
|
CAGE Questionnaire |
Cut Down, Annoyed, Guilty, Eye-Opener. |
|
AUDIT (Alcohol Use Disorders Identification Test) |
Assesses Hazardous & Harmful Drinking. |
|
SADQ (Severity of Alcohol Dependence Questionnaire) |
Measures Withdrawal Severity. |
Differential Diagnosis
|
Condition |
Key Differences |
|
Bipolar Disorder (Manic Episodes With Alcohol Use) |
Mood Swings Without Dependence. |
|
Delirium Tremens (Severe Alcohol Withdrawal) |
Hallucinations, Autonomic Instability, Confusion. |
|
Wernicke-Korsakoff Syndrome |
Thiamine Deficiency, Ataxia, Memory Loss. |
🔹 Diagnosis is based on history, collateral information, and screening tools.
Management (NICE Guidelines)
Acute Management (Withdrawal & Detoxification)
|
Scenario |
First-Line Treatment |
|
Mild-Moderate Withdrawal |
Chlordiazepoxide (Benzodiazepine Taper). |
|
Severe Withdrawal (Seizures, DTs) |
IV Lorazepam ± ICU Admission. |
|
Wernicke’s Encephalopathy |
IV Thiamine (Pabrinex). |
|
Severe Alcohol Intoxication |
Supportive Care, IV Fluids, Monitoring. |
🔹 Withdrawal management depends on severity and risk factors.
Long-Term Treatment & Relapse Prevention
|
Intervention |
Medication |
Purpose |
|
Anti-Craving Therapy |
Acamprosate |
Reduces Alcohol Cravings. |
|
Aversive Therapy |
Disulfiram |
Causes Adverse Reaction to Alcohol. |
|
Opioid Antagonist |
Naltrexone |
Reduces Alcohol Reward Effects. |
|
Harm Reduction |
Thiamine Supplements |
Prevents Wernicke-Korsakoff Syndrome. |
Psychological & Social Interventions
- Cognitive Behavioural Therapy (CBT) for Addiction.
- Motivational Interviewing (Enhancing Readiness to Change).
- 12-Step Programmes (Alcoholics Anonymous).
- Harm Reduction Strategies (Supervised Detox, Rehabilitation).
🔹 A combination of medication, therapy, and social support improves long-term recovery.
Prognosis & Complications
Prognosis
|
Condition |
Outcome |
|
Early Intervention & Abstinence |
Better Long-Term Recovery. |
|
Chronic Relapsing Alcohol Use |
Higher Risk of Liver Disease & Social Harm. |
Complications of Alcohol Dependence
|
Complication |
Features |
|
Liver Disease |
Cirrhosis, Alcoholic Hepatitis, Liver Failure. |
|
Neurological Damage |
Wernicke-Korsakoff Syndrome, Peripheral Neuropathy. |
|
Gastrointestinal Disease |
Gastritis, Pancreatitis, Mallory-Weiss Tears. |
|
Social Consequences |
Unemployment, Homelessness, Legal Issues. |
🔹 Early treatment reduces relapse risk and long-term harm.
UKMLA Key Points
- Best first-line treatment for alcohol withdrawal: Chlordiazepoxide (Benzodiazepine Taper).
- Best treatment for alcohol dependence: Acamprosate or Disulfiram.
- When to refer urgently: Severe withdrawal, Wernicke’s encephalopathy, suicidality.
- Best psychological therapy for alcohol dependence: CBT & Motivational Interviewing.