End-Stage Alcoholism

End-stage alcoholism, also referred to as ‘late-stage alcoholism’, is the last and final stage of an alcohol use disorder. This entails the severe mental and physical conditions caused by a lifetime of alcohol abuse.

Alcohol is the world’s most abused drug, consumed by over half of the adult population. Annually, alcohol takes over 100,000 lives due to its degenerative properties. [1] Alcoholism is a disease with a start, middle, and end-stage, leading to life-threatening medical conditions. [2]

Older definitions of alcoholism include an aspect of moral judgment and failing, reflecting historic views of religion and culture. These views that include responsibility and free will act as a scientific barrier to the medical definition of alcoholism.

The newly proposed definition, put forward by the National Council on Alcoholism and Drug Dependence and the American Society of Addiction Medicine, advises that alcoholism is a “heterogeneous disease influenced by multiple factors”. [3]

Whilst genetic information accounts for some traits seen in alcoholism, other factors such as the environment, impact the development of addiction. The 5^th edition of The Diagnostic and Statistical Manual of Mental Disorders (DSM) states that alcoholism is a disease and mental illness.

The DSM-5 defines alcoholism as: “a problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least two of the following [criteria], occurring within a 12-month period.”

It states that if you have experienced more than two of the following symptoms of the criteria, then you are likely suffering from an alcohol use disorder: [4]

1. Alcohol is often taken in larger amounts or over a longer period than was intended. [Do you drink more than you mean to?]
2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use. [Do you want to stop, but can’t?]
3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects. [Is drinking taking over your life?]
4. Craving, or a strong desire or urge to use alcohol. [If you can’t drink, are you thinking about drinking?]
5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home. [Is your drinking getting in the way of day-to-day activities?]
6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol. [Is drinking getting in the way of your relationships?]
7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use. [Are you sitting things out because of alcohol?]
8. Recurrent alcohol use in situations in which it is physically hazardous. [Are you drinking in risky settings, or doing risky things while drinking?]
9. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol. [Do you know drinking isn’t good for you, but you do it anyway?]
10. Tolerance, as defined by either of the following: a need for markedly increased amounts of alcohol to achieve intoxication or desired effect, or a markedly diminished effect with continued use of the same amount of alcohol. [Do you need to drink more than you used to?]
11. Withdrawal, as manifested by either of the following: the characteristic withdrawal syndrome for alcohol, or alcohol (or a closely related substance, such as a benzodiazepine) is taken to relieve or avoid alcohol withdrawal symptoms. [Do you feel it when you stop drinking?]

The presence of two or three of the above criteria represents a mild alcohol use disorder. Four or five of the criteria represent a moderate addiction, and more than six of the criteria suggest a severe alcohol use disorder.

Alcohol Use Disorder: What are the first symptoms?

The signs and symptoms of alcoholism may differ according to the person, and some symptoms may be harder to notice than others. Characterised by the inability to control alcohol intake, alcoholism leads to mental, physical, and social issues in someone’s life.

The following are common signs of a drinking problem, signs that may lead to a diagnosis of alcoholism:

Behavioural Symptoms:

• Secretive behaviour around where someone is, and their consumption of alcohol
• Lying about money, schedule, or drinking patterns
• Drinking alone
• Drinking during unsocial events or hours
• Withdrawing from important responsibilities
• Loss of interest in previously loved hobbies
• Avoiding social contact with loved ones

Physical and Mental Symptoms:

• Tiredness and lethargy
• Headaches and migraines
• Restlessness and insomnia
• Withdrawal symptoms such as shaking, sweating, anxiety, mood swings, and nausea
• Lack of personal hygiene
• Weight loss or weight gain
• Higher alcohol tolerance
• Depressive episodes
• Anxiety and constant worry

If these symptoms are left untreated, then alcoholism may progress into end-stage alcoholism.

End-Stage Alcoholism: Signs and Symptoms

During end-stage alcoholism, the alcohol use disorder has typically taken over someone’s life. This will have already had a severe impact on relationships and general health.

If the individual attempts to go ‘cold turkey’ or detox on their own at home, they may experience severe and life-threatening withdrawal symptoms.

The DSM-IV defined a diagnostic criterion for alcohol withdrawals: [5]

1. Cessation of or reduction in alcohol use that has been heavy or prolonged.

2. Two or more of the following symptoms have developed within hours to a few days after criterion 1:

• • Autonomic hyperactivity (for example, sweating or pulse greater than 100 beats per minute)
  • Increased hand tremors
  • Insomnia
  • Transient visual, tactile, and auditory hallucinations or illusions
  • Nausea or vomiting
  • Excessive, purposeless physical activity (i.e, psychomotor agitation)
  • Anxiety
  • Grand mal seizures.

3. The symptoms in criterion 2 cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

4. The symptoms are not attributable to a general medical condition and are not better accounted for by another mental disorder.

These withdrawal symptoms often appear around 6 hours after the last consumption of alcohol. Those with end-stage alcoholism are likely to suffer from delirium tremens and WKS if they try to cut out alcohol too quickly.

Delirium Tremens and Wernicke-Korsakoff Syndrome

Seizures happen to around 5% of people who are left untreated for alcoholism. Delirium tremens (DT) is the most severe seizure relating to alcoholism.

DT is said to develop around 4 days after initial withdrawals begin, characterised by hyperactivity of the nervous system and hallucinations.

Wernicke-Korsakoff Syndrome (WKS) is a symptom of nutritional deficiency (vitamin B1) caused by alcohol abuse. This is a condition that mirrors the symptoms of dementia, as the brain is not receiving enough thiamine.

Thiamine is a necessary requirement for the brain cells to carry out their functions properly, and therefore the lack of nutrition has long-lasting negative effects on the brain.

WKS has two independent stages. Stage one is called Wernicke’s encephalopathy, a swelling or inflammation of the brain. This then develops into a condition called Korsakoff’s syndrome, removing the ability to create new memories.

Also called ‘alcohol dementia’, WKS creates confusion and memory loss, leading people to create false memories to fill the gaps, whilst repeating questions or statements several times over. This may change aspects of someone’s personality and ensures difficulty in learning new skills and information.

Symptoms of End-Stage Alcoholism

This end stage of alcoholism caused by a prolonged period of heavy drinking or binge drinking leads to complex medical issues such as:

• Liver failure and jaundice
• Cirrhosis
• Itchy skin
• Fluid retention
• Chronic fatigue
• Malabsorption and malnutrition
• Chronic pancreatic
• Heart failure

Cirrhosis: Alcoholic Liver Disease

Cirrhosis is the term used to refer to scarring of the liver. This is late-stage liver disease caused by alcohol use, hepatitis, and other fatty liver issues. Healthy tissue on the liver is replaced by scar tissue as the liver becomes permanently damaged, stopping the liver from working properly.

Liver conditions and diseases damage healthy cells and cause inflammation and cell death. The cells aim to repair themselves but there is scarring as a result of this process.

The scar tissue prevents the flow of blood and hinders the processing of toxins, hormones, and other nutrients. Scar tissue also blocks the production of proteins that aid the liver’s function, this stops the liver from working properly and it will begin to fail.

The symptoms of alcoholic liver disease will not be obvious until the liver is already badly damaged:

• Feeling lethargic and week
• No appetite
• Losing weight
• Nausea and vomiting
• Pain and discomfort in the upper right area of the abdomen
• Jaundice (yellowing of skin and eyes)
• Dark urine
• Severe itchy skin
• Edema (the swelling of legs, ankles, and feet)
• Confusion and memory loss
• Bleeding easily
• Bruising easily

1 out of 5 heavy drinkers will suffer from cirrhosis, as alcohol removes the ability to break down scar tissue.

Cirrhosis is the final stage of alcohol-related liver disease: [6]

1. Alcoholic fatty liver disease: drinking too much alcohol even for a short period of time can lead to the build-up of fat in the liver. This doesn’t cause many noticeable symptoms and it is reversible by stopping drinking for a period of time.
2. Alcoholic hepatitis: this is the second stage of alcohol-related liver disease. Unrelated to infection hepatitis, alcoholic hepatitis is caused by alcohol misuse over a long period of time. This is common for binge drinkers, but it is reversible if you stop drinking immediately and permanently.
3. Cirrhosis: as the final stage of alcohol-related liver disease, there is no treatment for cirrhosis. The only thing patients may do to increase life expectancy is giving up alcohol for the rest of their lives, but a liver transplant may be required.

Cirrhosis can quickly lead to death if it is left untreated. This is because there is an increase of pressure withing the liver veins, causing a collection of fluid in the abdomen and bleeding in the oesophagus lining.

Chronic Pancreatitis

Drinking alcohol in excess may eventually attack the pancreas. Around 80% of chronic pancreatitis cases are the result of alcohol abuse.

The pancreas becomes severely inflamed, damaging the organ until it eventually stops working. [7]

Chronic pancreatitis is more severe than acute pancreatitis, where the inflammation of the pancreas is only short-term. The common symptom of chronic pancreatitis is a pain in the abdomen, with repeated episodes of burning or shooting pains that may last hours or days.

This pain often develops along the left side or middle of the stomach, and may move along the back. The discomfort usually does not have a trigger but has commonly started after eating when people become nauseous and vomit.

As the condition develops and becomes more severe, the pain may become constant but dull, followed by chronic episodes of severe pain.

For those with advanced chronic pancreatitis, the pancreas cannot produce any digestive juices or enzymes, which are used to break down consumed foods. If this is the case, stool may become smelly and often greasy.

This can also lead to:

• Severe weight loss
• Lack of appetite
• Jaundice (yellowing of the eyes and skin)
• Feeling thirsty
• Constant nausea and vomiting

Cardiovascular Issues

End-stage alcoholism consists of heart conditions that include:

• High blood pressure
• High heart rate
• Alcoholic cardiomyopathy (damaged heart muscle)
• Increased risk of heart failure
• Stroke
• Heart disease due to high blood triglycerides
• Angina, caused by a blocked coronary artery

Drinking lots of alcohol narrows the muscles in the blood vessels. This causes hypertension, increased blood pressure, and a high heart rate. This can cause significant chest pain and put additional stress on the heart muscle.

Long-term and heavy alcohol abuse can cause the heart to change shape, called alcoholic cardiomyopathy.

This condition can lead to heart failure, as the areas of the heart become enlarged and stretched. This weakens the heart muscles, preventing them from pumping blood and reducing the oxygen supply to the body.

Drinking too much alcohol too quickly can reduce the body’s ability to break it down properly. Heavy alcohol use strains the processes of metabolism and makes them less effective.

This causes:

• Chest pain
• Coughing
• Weakness and fatigue
• Heart palpitations
• High blood pressure
• Bulging of neck veins
• Difficulty breathing
• Edema
• Loss of appetite
• Atrophy (loss of muscle mass)
• Swelling of the liver

Heavy alcohol use has long been associated with angina and coronary artery disease (CAD). Angina pectoris is severe chest pain caused by the lack of blood flow into the heart, causing coronary artery disease.

This is likely caused by the high blood pressure induced by alcohol. This may feel like a tightness, pressure, or squeezing in the chest, which can also be signs of a more serious problem such as a stroke or heart attack.

End-Stage Alcoholism Treatment

The most common treatment for end-stage alcoholism is treating the alcohol use disorder itself. Without treating the underlying cause using rehabilitation and therapy, medicine and other medical treatment only mask the pain and discomfort.

The first step towards sobriety will likely be a medical detox, supervised and medicated to prevent dangerous withdrawal symptoms such as delirium tremens.

You will also be offered:

• Family or behavioural therapy such as cognitive behavioural therapy, rational emotive behaviour therapy, dialectic behaviour therapy and rapid eye movement desensitisation and reprocessing.
• Support groups such as Alcoholics Anonymous (AA), Narcotics Anonymous (NA), Smart Recovery, Rational Recovery, and Secular Organisations for Sobriety (SOS).

Once you have begun your journey to sobriety, your mind and body can start the healing process. If some of the conditions are not treatable, cutting out alcohol will prevent them from getting worse.

There are many treatment options available for all the stages of alcoholism. Alcohol addiction and excessive alcohol intake can be controlled and monitored throughout addiction treatment. 

Working with addiction and medical professionals can help you get your life back from alcohol, and it will be worth all the hard work you put in.

References

[1] Angell M, Kassirer JP. Alcohol and other drugs — toward a more rational and consistent policy. N Engl J Med 1994;331:537-539

[2] Rehm J. The risks associated with alcohol use and alcoholism. Alcohol Res Health. 2011;34(2):135–143.

[3] Keller, M., & Doria, J. (1991). On defining alcoholism. Alcohol Health and Research World, 15(4), 253. Retrieved from https://www.proquest.com/scholarly-journals/on-defining-alcoholism/docview/1474321816/se-2

[4] https://www.arkbh.com/alcohol/alcohol-use-disorder/dsm-5/

[5] Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (American Psychiatric Association 1994).

[6] https://www.nhs.uk/conditions/alcohol-related-liver-disease-arld/

[7] https://www.nhs.uk/conditions/chronic-pancreatitis/#:~:text=Chronic%20pancreatitis%20is%20a%20condition,is%20more%20common%20in%20men.

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