1. Screen annually using validated tool.

  2. AUDIT score ≥4 for men and ≥3 for women and SASQ reporting of ≥5 drinks in a day (men) or ≥4 drinks in a day (women) in the past year are valid and reliable screening instruments for identifying unhealthy alcohol use.

  3. The TWEAK and the T-ACE are designed to screen pregnant women for alcohol misuse.


  • –Adults


▶ VA/DOD 2009

  • –Provide brief intervention to those who have a positive alcohol misuse screen. Brief interventions during future visits.



  • –Adolescents children and adolescents


▶ AAFP 2010, USPSTF 2013, ICSI 2010

  • –Insufficient evidence to recommend for or against screening or counseling interventions to prevent or reduce alcohol misuse by adolescents.



  1. AUDITa and CAGE questionnaires have not been validated in children or adolescents.

  2. Reinforce not drinking and driving or riding with any driver under the influence.

  3. Reinforce to women the harmful effects of alcohol on fetuses.

aAUDIT, alcohol use disorders identification test; SASQ, single alcohol screening question.



provide persons engaged in risky or hazardous drinking with behavioral counseling interventions to reduce alcohol misuse.1

  1. For patients identified with alcohol dependence, schedule a referral to a substance use disorders specialist before the patient has left the office.

  2. Refer all patients with alcohol abstinence syndrome to a hospital for admission.

  3. Recommend prophylactic thiamine for all harmful alcohol use or alcohol dependence.

  4. Refer suitable patients with decompensated cirrhosis for consideration of liver transplantation once they have been sober from alcohol for ≥3 mo.

  5. Recommend pancreatic enzyme supplementation for chronic alcoholic pancreatitis with steatorrhea and malnutrition.



  1. Assess all patients for a coexisting psychiatric disorder (dual diagnosis).

  2. Addiction-focused psychosocial intervention is helpful for patients with alcohol dependence.

  3. Consider adjunctive pharmacotherapy under close supervision for alcohol dependence:

    1. Naltrexone

    2. Acamprosate





Alcohol functions as a depressant much like benzodiazepines and barbiturates.

It has an effect on serotonin and gamma-aminobutyric acid type A (GABA-A) receptors, producing tolerance and habituation.


Which of the following statements best reflects the effect of alcohol on neurotransmitters in the brain?

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The correct answer is C. You answered C.

The answer is C.(Chap. 467) Alcohol has effects on many neurotransmitters in the brain.

The predominant effect of alcohol lies in its ability to cause release of γ-aminobutyric acid (GABA), and it acts primarily at the GABAA receptors. GABA is the primary inhibitory neurotransmitter in the brain and is associated with the sedative effects of alcohol.

Many other drugs affect the GABA system including benzodiazepines, nonbenzodiazepine sleep aids such as zolpidem, anticonvulsants, and muscle relaxants. The euphoric effects of alcohol consumption are related to increases in dopamine, which is common to all pleasurable activities. The effects on dopamine are thought to be important in alcohol craving and relapse. In addition, alcohol alters opioid receptors and can lead to a release of β-endorphins during acute ingestion. In addition to these effects, alcohol also inhibits postsynaptic NMDA excitatory glutamate receptors. Glutamate is the primary excitatory neurotransmitter of the brain, and its inhibition further contributes to the sedative effects of alcohol. Additional important effects on neurotransmitters include increased serotonin activity and decreased nicotinic acetylcholine receptors.

Content 9


Complications of Injecting Drug Use

  • Local problems—Abscess (Figures 240-2 
    Image not available.

    A 32-year-old woman with type 1 diabetes developed large abscesses all over her body secondary to injection of cocaine and heroin. Her back shows the large scars remaining after the healing of these abscesses. (Courtesy of ­Richard P. Usatine, MD.)

    and 240-3; Abscess), cellulitis, septic thrombophlebitis, local induration, necrotizing fasciitis, gas gangrene, pyomyositis, mycotic aneurysm, compartmental syndromes, and foreign bodies (e.g., broken needle parts) in local areas.2
    • IDUs are at higher risk of getting methicillin-resistant Staphylococcus aureus(MRSA) skin infections that the patient may think are spider bites (Figure 240-4).
    • Some IDUs give up trying to inject into their veins and put the cocaine directly into the skin. This causes local skin necrosis that produces round atrophic scars (Figure 240-5).
  • IDUs are at risk for contracting systemic infections, including HIV and hepatitis B or hepatitis C.
    • Injecting drug users are at risk of endocarditis, osteomyelitis (Figures 240-6and 240-7), and an abscess of the epidural region. These infections can lead to long hospitalizations for intravenous antibiotics. The endocarditis that occurs in IDUs involves the right-sided heart valves (see Chapter 50, Bacterial Endocarditis).2 They are also at risk of septic emboli to the lungs, group A β-hemolytic streptococcal septicemia, septic arthritis, and candidal and other fungal infections.


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A 48-year-old woman is recovering from alcohol dependence and requests medication to help prevent relapse. She has a medical history of stroke occurring during a hypertensive crisis. Which of the following medications could be considered?

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The correct answer is D. You answered B.

The answer is D.(Chap. 467) In individuals recovering from alcoholism, several medications may have a modest benefit in increasing abstinence rates. The two medications with the best risk-benefit ratio are acamprosate and naltrexone. Acamprosate inhibits NMDA receptors, decreasing symptoms of prolonged alcohol withdrawal. Naltrexone is an opioid antagonist that can be administered orally or as a monthly injection. It is thought to act by decreasing activity in the dopamine-rich ventral tegmental area of the brainstem and subsequently decreasing the pleasurable feelings associated with alcohol consumption. There is some research to suggest that the use of these medications in combination may be more effective than either one alone. Disulfiram is an aldehyde dehydrogenase inhibitor that has been used for many years in the treatment of alcoholism. However, it is no longer a commonly used drug due to its many side effects and risks associated with treatment. The primary mechanism by which it acts is to create negative effects of vomiting and autonomic nervous system hyperactivity when alcohol is consumed concurrently with use of the medication. Because it inhibits an enzyme that is part of the normal metabolism of alcohol, it allows the buildup of acetaldehyde, which creates these unpleasant symptoms. As a result of the autonomic side effects, it is contraindicated in individuals with hypertension, a history of stroke, heart disease, or diabetes mellitus.

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