DIAGNOSIS AND MANAGEMENT OF ALCOHOL PROBLEMS

Approximately 14 million Americans suffer from alcohol abuse and dependen~e,’~ and drinking remains the most common cause of liver-related mortality in the United States. Forty-four percent of the 26,000 annual deaths from liver cirrhosis are attributed to alcohol use. Even this is likely to be an underestimate because certifying physicians may not be familiar with the decedent’s drinking history or may desire to protect the family from the stigma of a family member being an alcoholic.10 Alcoholic liver disease is also an important cause of morbidity. It has been estimated that between 15% and 30% of heavy drinkers develop advanced liver disease.I9 In 1990, cirrhosis was listed as a diagnosis on approximately 1% of discharges from nonfederal short-stay hospitals for those 15 years and older and was the principal diagnosis for 0.2% of the discharges. Underestimation of alcoholic liver disease on hospital discharge records may exceed that for death certificate^.^^ Because of the adverse effects of alcohol on the liver, alcoholdependent and alcohol-abusing patients commonly are seen in many hepatologists’ practices. Although findings on the physical examination and laboratory tests may provide clues, the diagnosis of alcoholism depends on the history provided by patients and their relatives. The two most commonly employed sets of criteria are the American Psychiatric Association‘s Diagnostic and Statistical Manual of Mental Disorders, ed 4 (DSM-IV)’ and in the World Health Organization’s International Classification of Diseases, 10th rev (ICD-10).36 Both are based on symptoms of alcohol dependence and abuse rather than specific thresholds of drinking frequency, quantity, or patterns. The term alcoholism has been dropped in favor of two distinct categoriesalcokol abuse and alcohol dependence. Alcoholic liver