The prevalence of alcoholism among general medical patients was evaluated in two French national surveys around 20% of consultants. However, only the most severe and clinically noisy form of the Alcohol disorders, alcohol dependence, is indicated in general practice.
The complexity of its management imposes a morbid form of more moderate tracking strategy (consumer issues) or better yet the premorbid stage (risky consumption) for which preventive intervention is required.
We propose to describe the clinical signs of each stage of disorders of alcohol by separating the excessive consumption (risky consumption and consumer issues) of consumer problems with alcohol dependence.
The excessive consumption of a challenge or by its ability to produce whatever damage their health nature relational, social or legal. This damage may be latent in an individual who has not gone to the act but whose quantitative or situational characteristics of consumption, identified in case-control studies, expose it to a statistical risk of development.
We define consumption as at risk. This damage may be obvious in this case and define consumer problems. However, two factors limit both the effectiveness of the registration and systematization:
– Most of these signs are functional symptoms commonplace, rarely spontaneously attributed to alcohol consumption by the patient or clinician;
– Assessment of alcohol consumption on qualitative and quantitative aspects of a subject remains delicate in our country.
Risk consumption is, by definition, subclinical. It can not be marked by a retrospective evaluation of the characteristics of alcohol consumption, ideally on the month before. The benchmarks proposed by WHO are:
– Qualitatively: the presence of a consumer (whatever the amount) in at-risk situations such as driving, pregnancy or security work;
– Quantitatively: a higher consumption than or equal to 14 units 1 per week for women and 21 units for men.
In practice, the diagnosis of risk drinking should be disposed of in any matter which is not declared clean. By definition, no clinical signs of a consequence of alcohol (alcoolopathie) is identifiable. The diagnosis is established on the descriptive assessment of the declared alcohol consumption over a typical week of alcohol (if possible take the previous week) if it is beyond the WHO thresholds. The prospective collection of self-assessment of the subject, stating the rule of the glasses can be helpful.
Consumer problems (or abuse):
Consumer problems is defined by the presence of a patent identifiable damage (alcoolopathie).
The involvement of alcohol consumption on the occurrence of the damage (somatic, mental, relational, social or legal) varies from one disorder to another. Very often, the damage grows on a state of vulnerability prior or in combination with another toxic (such as smoking) or other etiologic factors.
Signs of excessive consumption (alcoolopathie) may be general: coated tongue, hypertension, impotence, insomnia, Dupuytren’s disease, impaired general condition, poor oral hygiene, nervousness, loss of appetite, sweating, gynecomastia.
1. An international alcohol unit (IAU) is equivalent to one glass of alcoholic beverage (wine, beer, anise, whiskey, spirits, cider, etc.) as it is usually served in a drinking establishment. The amount is inversely proportional to titration but the content of each lens corresponds approximately to 10 g of pure alcohol.
Other call signs should attract attention:
– Cutaneous signs: scarring, bruising, telangiectasia, rosacea;
– Neurological signs: muscle atrophy of the extremities, or dysesthesia hypoesthesia of the lower limbs, a history of seizures, memory impairment or concentration, balance disorders;
– Gastrointestinal symptoms: diarrhea, epigastric pain, morning phlegm, hepatomegaly;
– Psychiatric symptoms: depression, suicide attempts, anxiety disorders, personality disorders, irritability.
Besides these physical complaints, signs of appeal to bring the doctor to question a patient about alcohol consumption can be varied: social problems (unemployment, debt), relational, legal (license withdrawals, complaints).
Some laboratory abnormalities are frequently encountered in patients with alcohol.
The most frequently used markers for labeling is the MCV (macrocytosis) and the elevation of GGT (GGT). The sensitivity of the combination of these two markers is acceptable.
If normal GGT, a new marker, the carboxy-deoxy-transferrin (CDT) is a utility still debated today.
In practice, problems with consumption diagnosis is confirmed by the identification of a alcoolopathie. He must lead a council argued Reduction of alcohol consumption referred to as a brief intervention.
CONSUMPTION PROBLEMS ALCOHOLISM:
The secondary diagnosis of alcohol dependence with consumer problems should be considered in two circumstances:
– Failure to respond to a proposal to reduce consumption below the risk threshold (brief intervention) in a subject identified as at risk or consumer problems;
– Presence of abnormal drinking behavior suggestive of mental and / or physical dependence.
The diagnosis of alcohol dependence is codified in international classifications (DSM-IV, ICD 10). Psychological dependence is characterized by the irrepressible desire to renew the consumption of alcohol, even in the absence of withdrawal, in case of termination of the socket. Moreover, patients may, in association with this important and sometimes compulsive appetite, difficulty controlling consumption: more than initially planned consumption, unsuccessful efforts to stop or decrease, significant time spent to obtain alcohol , consumption or recover from its effects.
One can also observe a progressive impairment in social, occupational, or relational, an abandonment of fun activities.
Despite the existence of some important consequences linked to this consumption, addicts fail to control their consumption.
Sometimes there is a phenomenon of tolerance (the need to drink more to achieve the desired effect), originally in a number of cases of physical dependence characterized by a withdrawal syndrome manifested by the appearance signs of progressive intensity abrupt cessation of alcohol (tremors, sweating, nausea, vomiting, insomnia) which regress with the absorption of alcohol, driving patients to alcooliser sometimes in the morning.
The withdrawal syndrome can sometimes complicate weaning accidents (seizures, delirium tremens) in the absence of appropriate preventive therapy.
Following the identification phase will require part of the diagnosis to the patient by taking damage identified by the patient and the doctor to allow him to seize the opportunity of a support adapted to his situation .
MONITORING ALCOHOL WITHDRAWAL:
Weaning is defined as stopping the use of alcohol, whether accidental or registering in a therapeutic perspective in the alcohol-dependent. We have at our disposal to date three types of cessation assistance. When the patient decided to stop drinking after realizing that the risks to which it is exposed are more important than the profits of alcohol, it will be offered three ways of achieving abstinence.
The outpatient detoxification can be done in 80% of cases with a patient addicted to alcohol, he is psychologically and / or physically.
It was decided by mutual agreement with the patient in the outpatient setting.
After eliminating the cons-indications to weaning (Box 1) it is established drug treatment and regular care on a one consultation every three days the first week. The second week, the appointment will further apart shall surely come to a consultation per month for at least one year.
Box 1. Contraindications to outpatient withdrawal
– Severe Physical dependence
– History of Delirium Tremens and seizure withdrawal
– Social isolation
– Failure of outpatient withdrawal
– Need for a family separation
– Severe concomitant somatic pathology
– Associated psychiatric pathology
The outpatient withdrawal will be done in two stages:
– The physical withdrawal;
– Psychological withdrawal.
The physical withdrawal is generally established during the first week. Therapy consists essentially of a sufficient hydration (2-3 L soft drink) and some drugs (Table I).
The dose of benzodiazepines will be at decreasing doses starting with 3 tab daily of Valium or Seresta® 1 tab to get to the evening on day 7 and day 8 stop Some patients with no physical dependence will not have need these benzodiazepines. The reducing of craving for alcohol, the Aotal® will perscrit at a dose of 2 tablets three times a day for a patient of more than 60 kg and 4 cp per day (2-1-1) to a patient of less than 60 kg. This treatment will be continued for a minimum of 6 months. The second appetite reducer alcohol available to us is the Révia®. It is prescribed at a dose of 1 tablet per day from the 8th day of withdrawal. The choice of these gearboxes will be based on the patient’s history.
The psychological withdrawal will last much longer and at this stage, treatment is speech by psychological support and regular consultations.
The semi-ambulatory withdrawal will be done in an addiction unit having a day hospital where patients are cared for every day of the week with a return home in the evening. This type of withdrawal is more suited to the patient who has a family environment and educational constraints (mothers among others). Drug treatment is the same as the outpatient detoxification.
The residential withdrawal be proposed to the patient with a very strong physical dependence on alcohol with a major withdrawal syndrome upon discontinuation of alcohol. Patients with a history of seizures and Delirium tremens will also hospitalized systematically to avoid another accident withdrawal. This residential withdrawal can be done either in a unit of addiction with inpatient beds, or in a department of internal medicine and / or specialty such as hepato-gastroenterology, neurology, etc. The duration of the withdrawal can vary from 5 to 10 days depending on the institutions. Service staff doing the detoxification should have the competence to effectively monitor patients using the Cushman withdrawal scale (Table II).
When the result of score between 0 and 7, a monitoring will be every 2 hours with a score calculation reassessed regularly, if the patient has no history. If his withdrawal score is above 8, it will be created a weaning protocol is 1 tablet of Valium 10® or 50® Seresta every 2 or 3 hours, unless the patient falls asleep. When a history of seizures and Delirium tremens are present, the weaning protocol will immediately put in place even if the scale is less than 8.
hen the score remains greater than 8 and less than 15, it can be implemented an additional treatment Solumedrol® 40 mg / day for 3 days. If the score remains above 15, the patient will have to spend in intensive care. Figures 1 and 2 allow for a summary of the weaning protocol.
Overall, while alcohol withdrawal whether voluntary or induced to date should take place without complications and serenely. We currently have a suitable treatment and recognized by the consensus conference on weaning. It only remains that the concept of time to help our patients maintain abstinence started either outpatient or residential; this time which will allow them to improve physically, psychologically, socially, etc. This can only be done with a joint working between health professionals and treatment.
The suspicion of a disorder of alcohol (risky consumption and consumer problems with or without alcohol dependence) should be suspected and investigated in all alcohol consumers (80% of the French adult population). An annual systematic approach can be recommended for all general medical consultant for whatever reason. It involves weekly evaluation of the declared alcohol consumption that eliminates the diagnosis of pathological drinking. In the case of the existence of an evocative sign of alcoolopathie, assessment of the declared alcohol consumption combined with a reduction in consumption and attempt a search for signs of addiction are used to guide the diagnosis towards a Consumer problems with or without alcohol dependence (Fig. 3).