Understanding the Signs of Alcohol Abuse in Patients

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Introduction

Alcohol abuse is the most widespread form of substance abuse in the U.S. Alcohol itself is not only easily accessible, but it is also relatively inexpensive. Many homes across America boast a stocked liquor cabinet and/or a modest wine cellar. As such, the abuse of alcohol affects all age groups, gender and races. The management of a patient who abuses alcohol is as complex as its abusers are diverse; as healthcare providers, it is imperative that we understand and identify the signs of alcohol abuse in patients.  

What Is Alcohol Abuse? 

Alcohol, or ethyl alcohol, is the intoxicating ingredient that is found in a variety of beverages.  Alcohol is produced through the fermentation process of sugars, starches, and yeast. It is a central nervous system depressant that can affect every organ in the body. Alcohol is swiftly absorbed from the stomach and small intestine into the bloodstream. From there, it is then metabolized by the liver in small amounts at a time. The remainder of the alcohol will continue to circulate through the bloodstream until the liver is able to handle it. The amount of alcohol consumed will determine the intensity of the effect on the body (2). 

In the U.S., a standard drink is about 14 grams or 0.6 ounces of alcohol; this amount is found in a variety of drinks (12).   

Alcohol abuse is a problem that can have long-lasting effects on both the abuser and those around them; it is when a person continues to consume alcohol despite it negatively impacting their health and life. In most cases, the abuser knows that their behavior is wrong, and they often have problems with their relationships, work, and other aspects of their lives. 

Binge drinking is defined as drinking to bring the blood alcohol to 0.08 grams of alcohol per deciliter or higher (9). This type of drinking, especially over extended periods of time, can lead to alcoholism and an alcohol use disorder diagnosis from a healthcare professional. There are, however, tools designed to determine if someone may have a drinking problem. If someone experienced two or more of the following scenarios over the past 12 months, it could indicate troublesome alcohol use/abuse: 

1. Inability to decrease or control alcohol consumption even though you have tried. 
2. Strong cravings to drink. 
3. Often drinking for a longer period than intended or drinking more than intended. 
4. Continuing to drink even though the drinking has caused problems with relationships. 
5. A lot of time is invested in doing alcohol related activities. 
6. Alcohol use is given priority over other important activities. 
7. Having symptoms of withdrawal when not drinking. 
8. Problems fulfilling responsibilities due to drinking. 
9. Using alcohol in situations where it can by physically harmful. 
10. Building up tolerance to alcohol. 
11. Continuing to drink even though it has become harmful (8). 

Special Populations 

Alcohol abuse can affect people from all walks of life. There are certain populations that are more susceptible to be abusers of alcohol. The effects and signs of alcohol abuse may differ from each population; however, the overall damaging consequences are paralleled. 

Adolescence (Underage)

Raise your hand if, as a young person, you had ever raided your parent’s liquor cabinet. Many youths have very easy access to all kinds of alcohol. In the U.S., alcohol is a significant factor in the deaths of young people every year. Young people tend not to drink as often as those who are of age do. However, when they do drink, they usually binge drink.  

The question remains, “Why do young people start drinking?” 

Pushing boundaries and asserting their independence may play a role in taking that initial drink. Watching their parents and mimicking that behavior is also a potential cause of drinking.  Perhaps the most influential factor in a young person’s decision to take their first drink is a result of peer pressure. The desire to feel that “buzz” of intoxication can keep a young person drinking at regular intervals (15).   

Pregnant Women 

Alcohol abuse affects all populations; however, pregnant women face special circumstances.  When you are pregnant, everything you consume is passed on to the baby – alcohol is no exception. The use of alcohol can have serious harmful effects on the baby as the alcohol gets absorbed into its system. These issues can be both physical and behavioral and potentially last throughout their entire lives; for example, babies born with the worst of these problems may have fetal alcohol syndrome. Some problems caused by fetal alcohol syndrome are being born small, problems eating, sleeping, trouble paying attention, trouble following directions, and they may require medical care for the rest of their lives (16). 

Older Adults 

About 40% of older adults (age 65 and older) consume alcohol on a regular basis; they have special circumstances. They have an increased sensitivity to alcohol and may feel the effects much quicker than when they were younger, which puts them at a higher risk for falls and injury. Older adults generally take more medication than their younger counterparts, raising the risks of alcohol-drug interactions; although these interactions can be minor, they could also be extremely dangerous and lead to death. The older adult may already have a health problem that can be severely exacerbated using alcohol (14). 

Symptoms and Signs of Alcohol Abuse

Once alcohol use starts to negatively affect a person’s life, it may have already become alcohol abuse, and it is important that they receive help. Alcohol abuse can cause serious harm to the body, mind, and spirit of a person. Here are some of the most common signs of alcohol abuse to look for: 

Blackouts and short-term memory loss.

These are gaps in a person’s memory of things that happened while they were intoxicated. This occurs when someone drinks enough alcohol to stop the transfer of memories from their short-term to their long-term memory (11). 

Irritability and extreme mood swings.

Alcohol is known to interfere with the brain’s communication pathways, and it can change the way the brain both perceives information and works. In turn, this can affect mood and behavior (13). 

Making excuses for drinking.

Finding a reason to drink when there really isn’t one. This is an attempt to justify the behavior and avoid feelings of guilt. 

Isolation and drinking alone.

This is often done in secret. Again, feelings of guilt may drive this behavior. 

Feeling hungover when not drinking.

As those who abuse alcohol are constantly intoxicated, when they stop drinking, they may experience a mini-withdrawal and feel hungover (5). 

CAGE Tool

The CAGE Tool is a brief, four question-long survey that can be used to determine if someone has an alcohol problem. Answering “yes” to two or more of the questions may indicate that the person has a problem with alcohol and that they should seek professional help. The questions in the CAGE Tool consist of: 

1. Have you ever felt you should cut down on your drinking? 
2. Have people annoyed you by criticizing your drinking? 
3. Have you ever felt bad or guilty about your drinking? 
4.  Have you ever had a drink first thing in the morning to steady your nerves or get over a hangover? (5).
   

Health Problems Associated with Alcohol Abuse

Signs of alcohol abuse can cause and exacerbate a multitude of health issues.   

Alcohol Overdose/Poisoning

Alcohol overdose occurs when the blood alcohol level becomes so elevated that it affects and begins to shut down the area of the brain that controls basic life support. Symptoms of alcohol overdose include confusion, trouble remaining conscious, vomiting, seizures, clammy skin, low heart rate, and low body temperature. Never assume that a person with these symptoms can just “sleep it off.” Their blood alcohol level can continue to rise as any remaining alcohol in their stomach/intestines absorb. With a loss of the gag reflex, this person can easily choke on their own vomit. Alcohol overdose is a very dangerous event that can leave a person with permanent brain damage and leave them dead (12). 

Liver Cirrhosis

Liver cirrhosis is an end-stage liver disease where healthy liver tissue is replaced over time by scar tissue. This scarring permanently damages the liver and prevents it from working properly. There are a variety of conditions that can contribute to liver cirrhosis, including alcohol abuse. The continued long-term abuse of alcohol injures the liver, and the scarring occurs, resulting in the organ being unable to process nutrients, hormones, drugs, or toxins. Late-stage liver cirrhosis can be life-threatening (4). 

Ascites

Ascites is the accumulation of fluid within the peritoneal cavity. Of the major complications of liver cirrhosis, ascites is the most common. Depending on the amount of fluid, ascites can have its own set of symptoms, including shortness of breath, abdominal pain, loss of appetite, and abdominal fullness. An ultrasound of the abdomen can be done to determine the presence and volume of ascites. Paracentesis can be performed to remove the fluid (3). 

Malnutrition

The body needs proper nutrition in order to function normally, to have enough energy, and to maintain its structure. Those that abuse alcohol tend to eat less; their daily consumption is mostly comprised of alcohol-containing beverages. Not only are they not eating as they should, but the alcohol itself can interfere with the nutrition process at all stages.  Alcohol can affect digestion, storage, utilization, and storage of the little nutrients that the alcohol abuser consumes. Malnutrition in these people can become life-threatening and is a cause for hospitalization. Restoring proper nutrition is one of the most important goals in the in-patient setting (1). 

Brain Damage

Just by having an increased blood alcohol level, a person can demonstrate symptoms of intoxication such as impaired balance, slurred speech, and slow reaction times.  Binge drinking can lead to blackouts and memory loss. Over time, continued alcohol abuse can bring about more serious and long-lasting brain conditions. As discussed above, alcohol abuse can impair the body’s ability to process nutrients.   

A thiamine deficiency can cause Wernicke–Korsakoff syndrome. This a 2-tier syndrome consisting of Wernicke’s encephalopathy and Korsakoff’s psychosis. Wernicke’s encephalopathy is characterized by severe confusion where a person may not even be able to find their way out of a room. Korsakoff’s psychosis presents as impaired memory and learning deficits. These people may remember life experiences and tell you all about them – 30 minutes later, they may not remember having that conversation with you (10). 

If the patient already has liver involvement, they may develop hepatic encephalopathy. When your liver can no longer perform its duty and remove toxins from the blood, they may build up and cause damage to the brain. 

Alcohol is also known to disrupt and prevent new brain cells from developing (10). 

Managing the Alcohol Abuse Patient 

When a patient who abuses alcohol is admitted to the hospital, whether for reasons directly related to the alcohol abuse or not, they come with a whole set of problems that need to be managed. Perhaps the most dangerous, even life-threatening, is the potential for the patient to go through delirium tremens (DT) associated with severe alcohol withdrawal.   

Alcohol withdrawal takes place with a sudden cessation of heavy long-term drinking. Several symptoms of alcohol withdrawal include (but not limited to) nausea, agitation, transient hallucinations, and generalized seizures. Severe alcohol withdrawal is characterized by seizures, hallucinations, disturbing tremors, and increased psychomotor activity. Delirium is the rapid onset of disturbances with the level of consciousness, cognition, psychomotor activity, and sleep-wake cycle. When severe alcohol withdrawal and delirium get together, we have the perfect storm of DT. DT is a relatively short-term condition usually only lasting three to four days and ending with a prolonged sleep. It tends to increase both hospital and ICU length of stay and mortality (6).   

DT is a medical emergency, and it needs to be treated as such, preferably in the ICU. In order to adequately to manage DT, it is essential that the symptoms of alcohol withdrawal be recognized and treated early. Benzodiazepines are the frontline treatment for DT. Light sedation will keep the delirium at bay and help curb any seizure activity. Thiamine infusion is also used to treat Wernicke’s encephalopathy. Other vitamins and nutrients are often added to the infusion to help treat malnutrition and dehydration associated with alcohol abuse. Pre-existing co-morbidities, severe electrolyte imbalance, and cardiac arrhythmias are among the causes of death with DT. It is important that these patients are monitored with a close eye on vital signs, labs, and cognition/level of consciousness. Seizure precautions should also be in effect.  Earplugs, eye masks, and other stimuli-reducing measures can be used. Items such as clocks and calendars can help keep the patient oriented. A family presence can also aid in the process.  Though historically used, restraints should only be used as a last resort as they often have the opposite to the desired effect and may increase agitation (6).   

Once the signs of alcohol abuse have been identified and the dangers of withdrawal have passed, there needs to be a focus on education. Both the patient and their support system (family, friends, etc.) need to be educated on the pitfalls of alcohol abuse, its long-lasting and often dangerous effects, and the resources available to help maintain a life of sobriety. 

Community Resources 

There are a variety of community resources available to help people that suffer from alcohol abuse. Below is a description of a few of these resources. 

Alcoholics Anonymous (AA)  

Perhaps the flagship of all sobriety programs, AA has become synonymous with recovery. Founded in 1935 by Bill Wilson and Dr. Bob Smith, AA has grown to more than 115,000 groups worldwide. AA is a community-based program that meets daily to discuss addiction. The only common denominator among the attendees is their alcohol abuse/addiction and their desire to stop. AA’s spiritual philosophy includes the famous 12 Steps of Recovery. The 12 Steps are: 

1. We admitted we were powerless over alcohol—that our lives had become unmanageable. 
2. Came to believe that a Power greater than ourselves could restore us to sanity. 
3. Made a decision to turn our will and our lives over to the care of God as we understood Him. 
4. Made a searching and fearless moral inventory of ourselves. 
5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs. 
6. Were entirely ready to have God remove all these defects of character. 
7. Humbly asked Him to remove our shortcomings. 
8. Made a list of all persons we had harmed and became willing to make amends to them all. 
9. Made direct amends to such people wherever possible, except when to do so would injure them or others. 
10. Continued to take personal inventory and when we were wrong promptly admitted it. 
11. Sought through prayer and meditation to improve our conscious contact with God, as we understood Him, praying only for knowledge of His will for us and the power to carry that out. 
12. Having had a spiritual awakening as the result of these Steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs. 

By following the 12 Steps, attending the meetings and being accountable to their mentor/peers it is possible for the alcohol abuser to overcome their addiction (8). 

Mothers Against Drunk Driving (MADD) 

MADD was created around a kitchen table in 1980 by a mother who was pained by the tragedy of losing a loved one to a drunk driving accident. The mission of MADD is to end drunk driving, help fight drugged driving, support the victims of these violent crimes, and prevent underage drinking. MADD stresses the importance of preventing underage drinking. They have resources to help parents start the conversations about drinking with their children/teens. MADD has created a parent/teen agreement that holds the teen accountable and emphasizes a commitment not to drink. Additionally, the group also has publications that are directed at young people. These resources equip today’s youth with accurate information about the harmful effects of alcohol in order to help them make wise decisions (7). 

SMART Recovery 

Many people have felt uncomfortable with the spiritual-based format of AA.  As a result, SMART Recovery was founded. SMART Recovery focuses on using scientific principles and evidence-based treatments to help participants abstain from alcohol use. They have developed a 4 Point Program as opposed to the 12 Steps used by AA. The 4 Points are: 

1. Building and Maintaining Motivation 
2. Coping with Urges 
3. Managing Thoughts, Feelings, and Behaviors 
4. Living a Balanced Life 

SMART Recovery characterizes alcohol abuse as behavior rather than a chronic disease.  They encourage their participants not to see themselves as powerless victims of a disease, rather they empower them to take control of these behaviors (17). 

Case Study #1

Jake is a 16-year-old teenage boy in the 11th grade. He has been stressed out due to this being final exam week. His friend’s parents are going away for the weekend, and they are planning a house party. Jake never has before consumed alcohol, but his friends have been telling him that they are going to get him drunk. On top of this, they have been assuring him that feeling “buzzed” is the best feeling ever. As Friday approaches, Jake has been feeling more and more nervous as his parents have previously spoken to him about the harmful effects of both drugs and alcohol.   

At the party, Jake and his friends play a drinking game where he drinks 4 alcoholic beverages in under 1 hour. Jake quickly shows signs of intoxication, including slurred speech, impaired balance, and loss of inhibition. After another hour, Jake’s friends find him “passed-out” on the kitchen floor. 

The next morning Jake wakes up with a hangover. He has an excruciating headache, feels very thirsty, and has nausea followed by vomiting. He does not remember anything from the previous night besides arriving to the party.    

What made Jake decide to drink? 

What type of drinking did Jake exhibit? 

Did Jake exhibit any signs of alcohol abuse?   

What were they? 

What are two signs of a hangover?

Case Study #2 

Mary is a 28-year-old woman who is pregnant with her second baby. She has been advised by her doctor that she needs to abstain from all alcohol consumption for the duration of her pregnancy. Prior to her pregnancy, Mary had been drinking 1 beer every evening after work.  She has found it very difficult to stop this behavior and has been drinking that beer at least 4 nights out of the week since she became pregnant.   

On the last ultrasound, it was noted that the baby was small for gestational age. Mary did not admit to the doctor that she has continued to drink through her pregnancy. She does not believe that there is a problem with her drinking and has the mentality that she can quit if and when she wants.  

Does Mary have a drinking problem? 

Is Mary aware of her problem? 

What alcohol associated health problem could her baby develop? 

What symptom of fetal alcohol syndrome did Mary’s baby exhibit? 

Is it okay for Mary to drink once in a while when pregnant?

Case Study #3

Bob is a 53-year-old male who has been a heavy alcohol drinker for the las 40 years.  At minimum, he drinks a six-pack of beer every day. Over the last few weeks, Bob has noticed a yellow hue to his eyes and skin. He has also become very bloated and has gained a significant amount of weight. He has a marked decrease in appetite and becomes short of breath with minimal exertion. Despite these symptoms, Bob continues to crave alcohol and has not stopped drinking. 

Last evening, Bob was rushed to the hospital due to shortness of breath. Upon arrival, Bob’s vital signs were relatively normal with a noted blood pressure of 130/70, HR of 101, and oxygen saturation of 94%. His abdomen was markedly distended, and he was slightly jaundiced. The ER physician ordered an abdominal ultrasound, and Bob was found to have large volume ascites. A paracentesis was performed, and after removing 6 liters of fluid, the procedure had to be stopped due to Bob’s decreased blood pressures of 85/40. 

Bob was admitted to the medical floor and was scheduled for a repeat paracentesis in the morning. 

Bob was educated on the harmful effects of alcohol abuse. A hepatologist consult was made, and Bob was discharged after 3 days in the hospital.  

Once home, Bob resumed his alcohol use and was readmitted 5 days later with his abdomen again distended. 

Does Bob have a drinking problem? 

What statement above indicates that Bob has a drinking problem? 

What health problem is Bob exhibiting as a result of his alcohol abuse? 

What are Bob’s symptoms of the alcohol-related health problem? 

What community resources are available to Bob?

Case Study #4 

Abigail is a 75-year-old woman who, after losing her husband last year, starting drinking alcohol daily. She states that the alcohol helps her forget all her problems. She has reported gaps in her memory since she started drinking. After a fall 2 years ago, Abigail started using a walker for her unsteady gait.  Abigail has underlying health issues such as diabetes type 2, and hypertension.  She takes 10 pills regularly but cannot voice what each pill is for. Her children used to visit her weekly, but Abigail started canceling these visits to hide her drinking. 

Does Abigail have a drinking problem? 

What factor lead to Abigail’s drinking? 

Which behaviors indicate Abigail’s problem? 

What puts Abigail at greater risk for injury due to alcohol consumption?

Case Study #5

Karen is a 38-year-old woman who drinks every weekend. She likes to go dancing at the club and finds that she can “cut loose” when she feels “buzzed.” On Saturday night, Karen and her friends each had 5 shots of tequila in less than 30 minutes and then continued drinking beer.  During the night, Karen became progressively less coherent and unable to control her bodily functions. Karen went outside to get some air and began vomiting and falling. She then had what on-lookers described as a seizure-like activity. A bystander rolled her onto her side and called 911; he also noted that she was very cold and clammy.   

EMS took her to the hospital, where she had her stomach pumped. She woke up not remembering anything that had transpired. 

Does Karen have a drinking problem?

What type of problem does Karen have?

Karen’s blood alcohol was at least what value? 

What health problem manifested itself on Saturday night? 

What are the symptoms of alcohol overdose? 

Conclusion

Alcohol abuse is a problem that affects people from all walks of life. It causes a myriad of social and health problems; some of which may be permanent. The management of the alcohol-abusing patient starts with early recognition and ends with educating the patient on ways to manage and deal with this problem independently. Though there are resources to help people control and stop their drinking, the best choice would be to never start.  

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