Alcohol dependence, as described in the DSM-IV, is a psychiatric diagnosis describing a physical dependence on alcohol.

For a person to meet criteria for Alcohol Dependence (303.90) within the criteria listed in the DSM-IV, they must meet 3 of a total 7 possible criteria within a 12 month period. The first 2 criteria are related to physiological dependence: Tolerance and Withdrawal. The 3rd and 4th criteria establish a pattern of losing control of drinking by breaking drinking rules or failing at attempts to quit or cut back. The 5th and 6th criteria are indicative of a progression of addiction as more and more time is spent on drinking and lifestyle changes result. The seventh criteria for Alcohol Dependence is met when a person continues to drink despite being aware that their drinking is causing or excacerbating some psychological or physiological problem(s). It is important to note that because only 3 criteria of 7 are required in order to be diagnosed with Alcohol Dependence, not all meet the same criteria and therefore not all have the same symptoms and problems related to drinking. Not everyone with Alcohol Dependence, therefore, experiences physiological dependence. Alcohol Dependence is differentiated from alcohol abuse by the presence of symptoms such as tolerance and withdrawal. Alcohol dependence is sometimes referred to by the less specific term alcoholism. However, many definitions of alcoholism exist, and only some are compatible with alcohol abuse. About 12% of American adults have had an alcohol dependence problem at some time in their life. [1] Alcohol Dependence is acknowledged by the American Medical Association as a disease because it has a characteristic set of signs and symptoms and a progressive course. Once a person is diagnosed with this incurable disease, it may go into remission but is not cured. Total abstinence from alcohol is medically indicated for remission to occur and a progression of the disease is likely as long as alcohol consumption is continued. Alcoholism, a crude term, runs parallel to Alcohol Dependence, the diagnostic term. Today's definition is still based upon early research: There has been a considerable scientific effort over the past three decades in to identifying and understanding the core features of alcohol and drug dependence. This work really began in 1976 when the British psychiatrist Griffith Edwards and his American colleague Milton M. Gross [2] collaborated to produce a formulation of what had previously been understood as alcoholism the alcohol dependence syndrome. The alcohol dependence syndrome was seen as a cluster of seven elements that concur. It was argued that not all elements may be present in every case, but the picture is sufficiently regular and coherent to permit clinical recognition. The syndrome was also considered to exist in degrees of severity rather than as a categorical absolute. Thus, the proper question is not whether a person is dependent on alcohol, but how far along the path of dependence has a person progressed. The following elements are the template for which the degree of dependence is judged: - Narrowing of the drinking repertoire. - Increased salience of the need for alcohol over competing needs and responsibilities. - An acquired tolerance to alcohol. - Withdrawal symptoms. - Relief or avoidance of withdrawal symptoms by further drinking. - Subjective awareness of compulsion to drink. - Reinstatement after abstinence.[3]

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An instantaneous full stop to a long, constant alcohol use can lead to delirium tremens, which may be fatal.

he Alcohol Use Disorders Identification Test The Alcohol Use Disorders Identification Test (the AUDIT questionnaire has been developed by the World Health Organization as a screening instrument for hazardous and harmful alcohol consumption. It is designed to be administered by primary health care workers. A copy can be printed using this guidance; The 10-item questionnaire takes about 2 minutes to complete, and covers alcohol consumption, drinking behaviour, and alcohol-related problems. A score of 8 or more in men and 7 or more in women indicates a strong likelihood of hazardous or harmful alcohol consumption. A score of 13 or more is indicative of significant alcohol-related harm/dependence and further assessment is advisable. Sensitivity is 92% (higher in men). Specificity is 93% (higher in women). Recent alcohol use is the focus of this test.

How do I know if there is dependence on alcohol? There is a high index of suspicion for dependence in men drinking more than 50 units/week and in women drinking more than 35 units per week. The diagnosis of alcohol dependence can be made using the ICD-10 criteria, according to which dependence is diagnosed if three or more of the following have been present at some time during the previous 12 months: o Strong desire/sense of compulsion to take alcohol o Difficulties in controlling alcohol intake behaviour in terms of its onset, termination, or levels of use o Physiological withdrawal state when alcohol use is ceased or reduced, as evidenced by characteristic withdrawal syndrome or use of alcohol to relieve or avoid withdrawal symptoms o Tolerance o Progressive neglect of alternative pleasures or interests, because of alcohol use, and the increased time needed to obtain alcohol or recover from its effects o Persisting with alcohol use despite harmful consequences (when it is confirmed that the patient is aware of potential harm)

How do I assess the degree of alcohol dependence? It is important to determine the degree of alcohol dependence, as this dictates management strategy which may involve for example, brief treatments, intensive interventions in specialist settings, or pharmacological detoxification. Indicators of high dependence include regular morning drinking; increased tolerance to alcohol; withdrawal symptoms (see above); relief drinking to avoid withdrawal symptoms; less ability to choose when to drink and when to abstain (stereotypical drinking); structuring of life around alcohol; 'blackouts' (episodes of memory loss); and previous withdrawal. Measurement of alcohol dependence is possible by questionnaire, e.g. the Severity Of Alcohol Dependence Questionnaire (SADQ). This is not routine in primary care.

Further evaluation Assessment of: o Physical health o Mental health o Vocational, social and interpersonal or relationship factors o Legal status and criminal activity o Poly-drug use and HIV or hepatitis risk-taking where relevant.

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Blood tests can be useful for diagnosis, for example of liver disease, in people drinking at harmful levels. Full blood count (FBC) may show raised mean corpuscular volume (MCV). Liver function tests (LFTs) may show raised transaminases, alkaline phosphatase or bilirubin, with raised alkaline phosphatase and bilirubin being indicative of serious liver damage. Monitoring progress. Following reduction/cessation of drinking, gamma-glutamyl transferase (GGT) levels return to normal after several weeks unless there is significant liver damage. MCV will remain elevated for months reflecting the 120-day lifespan of red blood cells".

The guideline continues by discussing the complications of problem drinking. Complications Alcohol-related mortality: estimates of alcohol-related deaths for England and Wales range from 5000 to 40,000 per year, and 25% of these deaths result from accidents. Cancer: Alcohol causes an increased risk of squamous cancers of the oropharynx, larynx and oesophagus (linear dose-response relationship). Heavy alcohol consumption is associated with cancers of the liver, stomach, colon, rectum, lung, and pancreas, and may be associated with breast cancer. Cardiovascular disease: Excessive alcohol consumption increases the risk of increased blood pressure (binge drinking may be particularly implicated), haemorrhagic stroke, coronary heart disease, cardiomyopathies and arrhythmias. Alcohol consumption of 1-2 units per day is believed to have a cardioprotective effect in men over 40 years and postmenopausal women and to protect against ischaemic stroke. Liver damage: In people who drink excessive amounts of alcohol liver damage is common. Fatty liver, present in 90% of persistently heavy drinkers, is usually asymptomatic. Alcoholic hepatitis occurs in about 40% of heavy drinkers and is often the precursor to cirrhosis. Between 8% and 30% of long-term heavy drinkers develop cirrhosis. It is thought that 20 units of alcohol daily for 5 years, in men, is probably the minimum intake associated with significant liver damage. Risk to the fetus: Maternal consumption of 15 units/week or more has been associated with a reduction in birth weight. Consumption in excess of 20 units/week is associated with intellectual impairment in children. Fetal alcohol syndrome (brain damage, prenatal and postnatal growth retardation and facial malformations) is relatively uncommon even among heavily drinking pregnant women. It occurs in approximately a third of children born to women who drink about 18 units/day. Psychiatric morbidity: This is common in heavy drinkers (excess of 10 units per day) and includes depression; suicide and attempted suicide; personality deterioration; sexual problems; hallucinations (auditory and visual, usually during withdrawal, but sometimes occurring without the other features of delirium tremens, and also rarer, distressing auditory hallucinations occurring in clear consciousness); alcohol dependence; amnesia; intellectual impairment; and delirium. Social consequences. It has been estimated that 30% of divorces, 40% of domestic violence and 20% of child abuse cases are associated with excessive alcohol consumption. Heavy drinking is also associated with workplace absenteeism, financial problems and homelessness. Delirium tremens can be complicated by fits, hyperthermia, dehydration, electrolyte imbalance, shock and chest infection. It is associated with appreciable mortality and urgent hospital admission must be considered. Other serious medical complications include gastrointestinal haemorrhage, pancreatitis, and neurological problems such as fits, neuropathy, acute confusional states, subdural haematoma, Wernicke's encephalopathy and Korsakoff's psychosis".

The guideline concludes by comparing inpatient versus community detoxification. "Abrupt cessation of alcohol can lead to withdrawal symptoms, therefore most people with alcohol dependence require controlled detoxification using a benzodiazepine. However, not every heavy drinker will suffer a withdrawal syndrome. For most people, inpatient detoxification is not routinely required. Outpatient or home detoxification may be appropriate, once it is established that the patient fulfils the following criteria: o Has no history of fits or delirium tremens o Is not a suicide risk o Has social support o Has no significant poly-drug misuse o Is not dependent on benzodiazepines 3|Page

Is not at risk of severe physical consequences, for example acute pancreatitis, haematemesis, cardiomyopathy, hepatic failure If these criteria are not met, then inpatient detoxification is indicated , with access to acute medical care. After withdrawal, outpatient community treatment is appropriate. A withdrawal plan should only be started if the person is sober enough to agree to the plan and to understand the principles involved. The patient should agree not to take alcohol during the period of medication. Depending on the level of home support, daily visits to the home can be made to provide support and monitor progress. It is useful to give an information leaflet to patients withdrawing at home. Long-term rehabilitation following detoxification is important in the prevention of relapse. This may involve the primary care team, community alcohol team and voluntary organizations. Clarification of long-term aims of management and education of the patient and family should be included in the rehabilitation. Prescribing drugs used for detoxification (e.g. benzodiazepines) should not be continued after the initial withdrawal period, as there is a high risk of dependency on these drugs. Long-term monitoring and support are important to the success of intervention, and all dependent drinkers need regular review of physical and psychological indicators of relapse. The frequency of follow-up depends upon clinical judgement of the severity of problems. It is suggested that heavy drinkers should be offered at least three or four follow-up appointments in the year after the initial assessment, with more intensive follow-up for severe problem drinkers and dependent drinkers. In all cases, long-term support from a spouse/partner/close friend will aid progress". o

Drug tolerance
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Drug tolerance occurs when a subject's reaction to a psychoactive drug (such as a painkiller or intoxicant) decreases so that larger doses are required to achieve the same effect. Drug tolerance can involve both psychological drug tolerance and physiological factors.

[edit] Conditioning
Tolerance may be related to familiarity of "drug onset cues". For example, the mind and body can become conditioned in response to environmental cues such as the sight of a needle or an alcoholic beverage, and therefore can produce the foundation of physiological responses before an actual drug is introduced to the body. [1] Thus, if there is no drug that follows said perception, or, if the dose is too small to produce the expected effect, such can trigger intense cravings in the addict. Exemplified, this theory may explain why "just one drink", or even just the sight or presence of familiar alcohol cues can cause a relapse in the case of a recovering alcoholic. Tachyphylaxis is a medical term referring to the rapid development of drug tolerance.

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