Alcohol use disorders involve four problem areas:

• A strong need, or urge, to drink (craving)
• Not being able to stop drinking once drinking has begun (loss of control)
• Withdrawal symptoms, such as nausea, sweating, shakiness, and anxiety after stopping drinking (physical dependence)
• The need to drink greater amounts of alcohol to get “high” (tolerance).

Alcohol dependence (alcoholism) refers to a repetitive pattern of excessive alcohol use with serious adverse consequences, often including lack of control, tolerance, and withdrawal.

Alcohol abuse is a milder category that refers to continued drinking despite adverse consequences,  in the absence of dependence (75).  Data from the 2001 to 2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) showed that alcohol use disorders have an annual prevalence rate of 7.35% in the United States (76). As many as 5 out of 6 patients who meet diagnostic criteria for abuse or dependence go unrecognized in primary care settings (77).

When diabetes and alcohol use disorders coexist, they represent a considerable clinical challenge. Alcohol-induced fasting hypoglycemia can occur 6 to 36 h after alcohol intake in the context of low food intake. Fasting depletes liver glycogen stores and alcohol impairs gluconeogenesis.  Neuroglycopenic symptoms are predominate and can include stupor and coma (78).

Chronic alcohol use can create medical and behavioral problems, including: blackouts, chronic abdominal pain,  depression,  liver dysfunction,  hypertension,  sexual dysfunction, sleep disorders, and work or interpersonal problems (79).

It can also affect nutritional status in type 2 diabetes, through direct changes to carbohydrate, lipid, and protein metabolism, but also indirectly by changing eating habits (e.g., meals become irregular or skipped). Chronic use can also promote hyperglycemia by the extra calories consumed and by enhancing insulin resistance and glucose intolerance (80). Early detection is important and can be supported by use of the widely used CAGE assessment (81). After asking the patient whether or not they drink alcohol and if the answer is ‘yes’ then establishing the types, amounts, and frequency of drinking, the following four questions are presented to the patient:

• C: Have you ever felt you should CUT down on your drinking?
• A: Have people ANNOYED you by criticizing your drinking?
• G: Have you ever felt bad or GUILTY about your drinking?
• E : Have you ever had a drink first thing in the morning as an EYE OPENER?

CAGE can reveal problem areas that should be further explored. Individuals at risk include those with one or more positive CAGE responses. Alcohol dependence requiring referral is likely if the patient gives 3 to 4 positive responses for the past year (79).

Garry W. Welch, Alan M. Jacobson, and Katie Weinger
Behavioral and Mental Health Research, Joslin Diabetes Center, Boston, Massachusetts, U.S.A.

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