Alcohol Use

Alcohol has almost immediate effects because it is absorbed faster than it is processed (metabolized) and eliminated from the body. As a result, alcohol levels in the blood rise rapidly. Effects can occur within a few minutes of drinking.

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Effects vary greatly from person to person. For example, people who drink regularly (2 or more drinks per day) are less affected by a given amount of alcohol than those who normally do not drink or drink only socially, a phenomenon termed tolerance. People who have developed tolerance to alcohol may also be tolerant to other drugs that slow brain function, such as barbiturates and benzodiazepines.

Effects vary depending on the level of alcohol in the bloodstream, which is usually expressed in the United States in terms of milligrams per deciliter (1/10 liter of blood), abbreviated mg/dL and in other parts of the world as millimoles per liter abbreviated mmol/L. Actual blood levels required to produce given symptoms vary greatly with tolerance, but in typical users who have not developed tolerance, the following symptoms are typical:

• 20 to 50 mg/dL (4.3 to 10.9 mmol/L): Tranquility, mild drowsiness, some decrease in fine motor coordination, and some impairment of driving ability

• 50 to 100 mg/dL (10.9 to 21.7 mmol/L): Impaired judgment and a further decrease in coordination

• 100 to 150 mg/dL (21.7 to 32.6 mmol/L): Unsteady gait, slurred speech, loss of behavioral inhibitions, and memory impairment

• 150 to 300 mg/dL (32.6 to 65.1 mmol/L): Delirium and lethargy (likely)

• 300 to 400 mg/dL (65.1 to 86.8 mmol/L): Often unconsciousness

• ≥ 400 mg/dL (≥86.8 mmol/L): Possibly fatal

Vomiting is common with moderate to severe alcohol intoxication. Because people may be very drowsy, vomited material may enter the lungs (be aspirated), sometimes leading to pneumonia and death.

In the United States, all states define driving with a blood alcohol content (BAC) at or above 80 mg/dL (17.4 mmol/L; 0.08%) as a crime, but specific state laws and penalties vary.

In people who do not drink regularly, a blood alcohol level of 300 to 400 mg/dL (65.1 to 86.8 mmol/L) often causes unconsciousness, and a blood alcohol level of ≥ 400 mg/dL (≥ 86.8 mmol/L) can be fatal. Death can occur due to impaired breathing or abnormal heart rhythms (arrhythmia), especially when large quantities are drunk rapidly. Low blood pressure and low blood sugar levels can be caused by drinking large amounts of alcohol.

The effects of a particular blood level differ in chronic drinkers. Many seem unaffected and appear to function normally with relatively high levels, such as 300 to 400 mg/dL (65.1 to 86.8 mmol/L).

Alcohol, even in moderate doses, interferes with short-term memory formation which may cause blackouts. The intoxicated individual may seem gregarious and loquacious but will have limited memory of the blackout period.

Prolonged use of excessive amounts of alcohol damages many organs of the body, particularly the liver (alcohol-related liver disease). Because people may not eat an adequate diet, they may also develop severe vitamin and other nutritional deficiencies.

Alcohol-related liver disease includes liver inflammation (hepatitis), fatty liver, and liver scarring (cirrhosis). An alcohol-damaged liver is less able to rid the body of toxic waste products, which can cause brain dysfunction (hepatic encephalopathy). People developing hepatic encephalopathy become dull, sleepy, stuporous, and confused and may lapse into a coma. Hepatic coma is life threatening and needs to be treated immediately.

Usually, people with liver failure also have liver flap (asterixis). When the arms and hands are outstretched, the hands suddenly drop, then resume their original position. Liver flap resembles but is not a tremor.

Cirrhosis of the liver causes pressure to build up in the blood vessels around the liver (portal hypertension). Built up pressure in these blood vessels can cause swelling of blood vessels in the stomach and esophagus (varices). These swollen vessels can rupture and bleed heavily, causing people to vomit blood. This bleeding is a particular problem because the damaged liver does not produce enough of the substances that make blood clot.

Inflammation of the pancreas (pancreatitis) can be caused by excessive alcohol use. People develop severe abdominal pain with vomiting.

Damage to the nerves and parts of the brain also can be caused by excessive alcohol use. When the nerves to the arms and legs (peripheral nerves) are affected, people may have loss of sensation or feel pins and needles in their hands and feet. People may develop a chronic tremor. Damage to the part of the brain that coordinates movement (cerebellum) can lead to poorly controlled movement of the arms and legs and affect balance. Heavy long-term alcohol use can result in irreversible brain damage and psychosis. It can also damage the lining (myelin sheath) of nerves in the brain, resulting in a rare disorder called Marchiafava-Bignami disease. People with this disorder become agitated, confused, and demented. Some develop seizures and go into a coma before dying.

A severe deficiency of thiamin, a B vitamin, can be caused by heavy long-term use of alcohol. This deficiency can lead to Wernicke encephalopathy (a condition characterized by confusion, inability to coordinate while walking, or difficulty coordinating movement of the eyes), which, if not promptly treated, may result in Korsakoff syndrome, coma, or even death.

Existing depression may be worsened by drinking alcohol, and people with alcohol use disorder are more likely to become depressed than people who are not problem drinkers. Because alcohol-related disorders, especially binge drinking, often causes deep feelings of remorse during dry periods, people with alcohol use disorder are prone to suicide even when they are not drinking.

Severe problems in the developing fetus, including low birth weight, short body length, small head size, heart damage, muscle damage, and low intelligence or intellectual disability, can be caused by alcohol use in pregnant women. These effects are called the fetal alcohol syndrome. Avoidance of alcohol is therefore recommended during pregnancy.

If people who drink continually for a period of time suddenly stop drinking, withdrawal symptoms are likely. For example, withdrawal can occur during hospitalization (for example, for elective surgery) because drinkers are unable to obtain alcohol.

Withdrawal symptoms vary from mild to severe. Severe untreated alcohol withdrawal can be fatal.

Mild to moderate withdrawal usually begins within 6 hours after drinking stops. Mild symptoms include tremor, headache, weakness, sweating, and nausea. Some people have seizures (called alcohol-related epilepsy or rum fits).

Alcohol-related hallucinosis

Delirium tremens (DTs) is the most serious group of withdrawal symptoms. Usually, delirium tremens does not begin immediately. Rather, it appears about 48 to 72 hours after the drinking stops. People are initially anxious. Later, they become increasingly confused, do not sleep well, have frightening nightmares, sweat excessively, and become very depressed. The pulse rate speeds up and the blood pressure rises. Fever typically develops. The episode may escalate to include fleeting hallucinations, illusions that arouse fear and restlessness, and disorientation with visual hallucinations that may be terrifying. Objects seen in dim light may be particularly terrifying, and the people become extremely confused. Their balance is impaired, sometimes making them think the floor is moving, the walls are falling, or the room is rotating. As the delirium progresses, a persistent tremor develops in the hands and sometimes extends to the head and body. Most people become severely uncoordinated. Delirium tremens can be fatal, particularly when untreated.

Emergency treatment is needed when very large amounts of alcohol consumed or alcohol withdrawal causes moderate to severe symptoms.

There is no specific antidote for acute intoxication:

• Observation and monitoring until the person is sober

• Coffee and other home remedies do not reverse the effects of alcohol.

• If people are in a coma or their breathing is suppressed, they may need to have a tube inserted in their airway to keep them from choking on vomit and secretions and to help them breathe.

• Fluids are given intravenously if needed to prevent or treat dehydration or low blood pressure.

• Suspected chronic alcohol drinkers are given thiamin to prevent Wernicke encephalopathy. Often, doctors also add magnesium (which helps the body process thiamin) and multivitamins (for possible vitamin deficiencies) to the fluids.

For alcohol withdrawal symptoms, doctors often prescribe a benzodiazepine (a mild sedative) for a few days. It reduces agitation and helps prevent some withdrawal symptoms, seizures, and delirium tremens. Because people can become dependent on benzodiazepines, these medications are used for only a short time. Antipsychotic medications are sometimes given to people with alcohol-related hallucinosis.

Delirium tremens can be life threatening and is treated aggressively to control the high fever and severe agitation. People are treated in an intensive care unit if possible. Treatment usually includes the following:

• High doses of benzodiazepines and barbiturates, given intravenously

• High doses of vitamins (especially thiamin)

• Fluids given intravenously

• External cooling measures such as cooling blanket

• Medications that control heart rate and blood pressure

• Treatment of complications (such as pancreatitis, pneumonia, and seizures)

With such treatment, delirium tremens usually begins to clear within 12 to 24 hours of its beginning, but severe cases may last for 5 to 7 days. Most people do not remember events during severe withdrawal after it resolves.

After any urgent medical problems are resolved, further treatment depends on the severity of alcohol use and the person's other medical and mental health disorders. If people have not become dependent on alcohol, doctors may discuss the serious consequences of alcohol use with them, recommend ways to reduce or stop their drinking, and schedule follow-up visits to check on how well they are doing.

For people with more severe alcohol use, particularly those who have coexisting medical and mental health disorders, a detoxification and rehabilitation program may be recommended.

In the first phase of detoxification and rehabilitation, alcohol is completely withdrawn, and any withdrawal symptoms are treated. Then people with alcohol use disorder have to learn ways to modify their behavior. Without help, most problem drinkers relapse within a few days or weeks. Rehabilitation programs, which combine psychotherapy with medical supervision, can help. People are warned about how difficult stopping is. They are also taught ways to enhance the motivation to stop and to avoid situations that are likely to trigger drinking. Treatment is tailored to the individual. These programs also enlist the support of family members and friends. Self-help groups, such as Alcoholics Anonymous, can also help.

• Facial flushing

• A throbbing headache

• A rapid heart rate

• Rapid breathing

• Sweating

Nausea and vomiting may follow 30 to 60 minutes later. These uncomfortable and potentially dangerous reactions last 1 to 3 hours.

• Pregnant women

• People who have a serious illness such as heart failure

• Older people

hepatitis or certain other liver disorders.

is a drug that affects certain parts of the brain and is typically used for high blood pressure but can help relieve some of the effects of alcohol withdrawal.