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A 38-year-old mother, wife and assistant bank manager was seen in the ER yesterday. She had been in a motor vehicle accident, hitting a telephone pole. In the ER, she was found to have two fractured ribs and multiple contusions.
Her labs included the following:
aspartate transferase: 170;
alanine transaminase: 60;
alkaline phosphatase: 220; and
total bilirubin: 1.1.
A complete blood count (CBC) showed hemoglobin of 10.6, a mean corpuscular volume of 104, a white blood cell count of 4 and a platelet count 110,000. Her blood alcohol test (BAC) was 220.
Philip A. Bain
She was transported to the ER by paramedics. Law enforcement issued an operating while intoxicated/impaired (OWI) ticket. She was discharged and asked to follow up with her primary care provider. In the office the next day, she was anxious, diaphoretic and trembling. Vital signs included a heart rate (HR) of 110 BPM, BP of 90/60 and respiration rate of 12. Her face was flushed. She did not give much history to the medical assistant (MA) who checked her in, saying, “I just want to talk to the doctor.”
The MA presented the patient to the physician.
“Doc, this 38-year-old female was seen in the ER yesterday after an accident. She hit a telephone pole and totaled her car. She was taken to the ER, where she was found to have two fractured ribs and a bunch of bruises. Her BAC was 220. Her liver tests were off. Today, she is really nervous, sweaty and shaky, with an elevated HR. Her BP is low, but she has run a low BP every time that you have seen her in the past. She really did not want to give me any more history.”
The physician reviews her chart, the ER notes and the police report. After asking how he could best help her, she started sobbing.
“Doctor, my whole life is a mess. I was on my way to pick up my son at his soccer practice when I became distracted and hit a telephone pole. My car was totaled. I was arrested. My husband is furious with me and has threatened to leave me. I am probably going to lose my job at the bank with this OWI. My boss confronted me in the past about getting help for my drinking. I just can’t stop drinking."
The physician continued to gather more history. She reported drinking four to eight glasses of vodka every day, sometimes in the morning before she went to work. Her husband has a history of alcohol use disorder (AUD) and has been sober for 3 years. They have been arguing much more lately, and she has been stressed out a lot about bills piling up. Her son was recently suspended from school for smoking pot at school. She started drinking in middle school. Both her mom and dad were alcoholics. In high school, she was “a big partier.” She was on the prom court but could not remember much because she passed out on the dance floor, which caused quite a scene. She and her husband have been married for about 10 years, and she remembers getting very drunk at her wedding reception. She has been in inpatient rehab twice and has also participated in intensive outpatient therapy. She tried going to Alcoholics Anonymous but really did not connect with the group.
On physical exam, she had a flushed appearance and was quite tremulous and diaphoretic. Her elevated HR was noted. Her liver size was increased. She had numerous bruises on her chest and upper back.
The physician empathized with her situation and offered her a few options. Her AUDIT PC score was 17 — consistent with high-risk drinking. Her Clinical Institute Withdrawal Assessment – Alcohol revised (CIWA-Ar) score was 15 — consistent with moderate withdrawal. She did not want to be treated as an inpatient. She had no history of withdrawal delirium or seizures. He gave her a small amount of chlordiazepoxide — prescribing a fixed dose of 50 mg four times a day on day 1, 50 mg three times a day on day 2, 50 mg two times a day on day 3, and 50 mg once a day on day 4, with five extra doses as needed for severe breakthrough symptoms. He recommended that she be started on oral naltrexone 50 mg daily. He referred her to a comprehensive alcohol treatment program that would involve a cognitive behavioral therapy-based intervention by a therapist and regular support group meetings. Because of her experience with AA in the past, she was referred to a SMART recovery program. Follow-up was arranged for 2 weeks. He recommended that they connect via telephone or Zoom on a daily basis until the risk for withdrawal has passed. She was asked to fill out the CIWA-Ar scale before the spoke each day.
At the 2-week visit, the patient was much less tremulous, although still anxious. She was able to complete the chlordiazepoxide taper but still craved drinking. In that 2-week period, she had been abstinent 3 to 4 days and drank on the other days, two to four drinks per day. Liver function tests (LFTs) were repeated and were about the same as in the ER. The physician increased the dose of naltrexone to 100 mg daily. She had not been to a SMART recovery meeting yet, although she had had an intake visit with the alcohol use therapist.
In 2 weeks, she returned and was still drinking, although only about 3 to 4 days per week, with one to three drinks per day. She still had significant cravings. The physician added acamprosate 666 mg twice a day. The patient was modestly compliant with her naltrexone but had difficulty remembering to take it every day. Her physician switched her to intramuscular (IM) naltrexone 380 mg every 4 weeks. With the help of her alcohol and other drug abuse counselor, she was able to secure a 6-week medical leave of absence from her employer. Her husband was attending Al-Anon for Families and was relieved to have some support from other families. The patient was asked to follow up in a month. At that visit, her LFTs were repeated and were nearly back to normal. She was doing better and had only “slipped” once in the past month but quickly contacted her sponsor who helped her problem solve about ways to prevent relapse. She was eager to return to work and planned on continuing to work with her therapist and attend meetings regularly.
She was seen back in 3 months and continued to remain abstinent. She was working and enjoying her job again. She and her husband were getting along better. She remained hopeful that she could maintain long-term sobriety.
Lessons learned
Risky alcohol use is very common. Nearly 40% of adults in the United States consume alcohol in an unhealthy manner. AUD is diagnosed when use of alcohol is associated with significant social, personal, legal, and/or occupational consequences.
Excessive alcohol consumption is one of the leading causes of preventable death in the U.S. More than 178,000 deaths per year in the U.S. are attributable to alcohol use, according to the CDC.
AUD is thought to stem from a complex interplay of genetics, personality traits and psychosocial stressors. It affects people from all walks of life, regardless of income, education or upbringing. In my decades of practice, nearly always patients with AUD were not bad people, but rather good people with a bad problem. They deserve as much empathy as someone with diabetes, hypertension or colitis.
Symptoms in patients with AUD may range from no symptoms to profound symptoms, including seizures, blackouts and tremors.
A wide range of lab abnormalities are associated with AUD and include abnormal LFTs, CBC and bleeding parameters.
Many effective screening tools are available to diagnose unhealthy alcohol use, including CAGE and AUDIT PC.
Treatment consists of medications and behavioral health interventions. Peer and family support groups play an important role in recovery. Wraparound social programs can also boost abstinence rates.
Alcohol withdrawal symptoms can be assessed using the CIWA-Ars. It is important to realize that treatment of alcohol withdrawal is not the same as treatment for alcohol use disorder. Enlarge Here’s how the scoring system works:
Symptom categories have scores of 0 up to 7.
Total scores of less than 8 to 10 indicate minimal to mild withdrawal.
Scores of 8 to 15 indicate moderate withdrawal (marked autonomic arousal).
Scores of 15 or more indicate severe withdrawal (impending delirium tremens).
Click here for the full scoring sheet. Generally, withdrawal in the ambulatory setting can be considered for those without a history of alcohol withdrawal delirium or seizures and a CIWA-Ar score of 15 or less. The patient should not be left alone and should touch base with someone in the office daily with CIWA-Ar scoring done prior to the contact. Medications include benzodiazepines and gabapentin. Chlordiazepoxide 50 mg four times daily and tapered over 5 days is an effective regimen to minimize withdrawal symptoms. Lorazepam is another safe option because it is not primarily metabolized by the liver. Fixed dosing is a better option because it is less confusing and is front loaded.
Medications for AUD include naltrexone (oral or IM), acamprosate and, in some individuals, disulfiram. Naltrexone should not be started for at least 24 hours after last alcohol use because it can worsen withdrawal symptoms. With moderate to severe AUD, sometimes twice-daily dosing of naltrexone is more helpful. Acamprosate is considered second-line treatment because it has to be started at least 3 days after last use of alcohol and is dosed three times daily. Topiramate is often more helpful for cravings than acamprosate. Disulfiram is considered to be third-line treatment and should be used if dosing can be observed by a family member or support person daily.
Relapse is common in AUD, and patients have to be proactive about relapse prevention and treatment. AUD is a treatable disorder with long-term sobriety possible for many individuals with good social support, access to medication and regular medical follow-up.
National Institute on Alcohol Abuse and Alcoholism. Unpublished data from the 2012–2013 National Epidemiologic Survey on Alcohol and Related Conditions III (NESARC-III), a nationwide survey of 36,309 U.S. adults aged 18 and older. https://www.niaaa.nih.gov/strategic-plan/references. Accessed April 26, 2024.
Nehring SM, et al. Alcohol use disorder. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. https://www.ncbi.nlm.nih.gov/books/NBK436003. Accessed April 26, 2024.
