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CE ARTICLE The staff says when he arrived 48 hours ago, he was conscious, fully alert and oriented, and able to interact normally with staff. Since then he's become increasingly agitated and earlier this morning developed an altered mental status. Your exam reveals the patient to be alert but altered and unable to answer questions appropriately, and he appears to be hallucinating. He is noticeably diaphoretic and vomits during the exam. His vital signs are a heart rate of 104/ min., respiratory rate of 22/min. with good tidal volume, blood pressure of 152/100 mmHg, and a room air SpO 2 of 96%. He has left-sided weakness and a facial droop, which the staff reports is no worse than when he arrived. You note on his chart that prior to his stroke he had a history of hypertension treated with amlodipine (Norvasc). Defnitions Prior to 2013 the American Psychiatric Association described two distinct disorders of alcohol in its Diagnostic and Statistical Manual of Mental Disorders (fourth edition, aka DSM–IV). Alcohol abuse and alcohol dependence were clas- sified separately, with specific criteria for the diagnosis of each. In May 2013 the APA issued the fifth edition of the DSM (DSM–5), which integrated the two DSM-IV disorders into the single alcohol use disorder (AUD). AUD is stratified into mild, moderate and severe classifications (Table 1). Any person meeting any two of the 11 criteria listed in Table 1 would receive a diagnosis of AUD. The severity of an AUD is based on the number of criteria met. 1 The term alcoholism is often used to describe more severe manifestations of AUD. 2 The Joint Committee of the National Council on Alcoholism and Drug Dependence and the American Society of Addiction Medicine defines alcoholism as a primary, chronic disease with genetic, psychosocial and environmental factors influencing its development and manifestations. The disease is often progressive and fatal. 3 That the term disease is used in the definition is not trivial, and is an important concept for healthcare providers at any level to appreciate. Addiction, including alcohol addiction, is thought to be the result of the inter- action of our genes with the environment, the duration of a drug exposure, and an individual's balance between personal risk and the socioeconomic protective factors present in their home, school and community. 4 Over the past two decades, our understanding of addiction has evolved. Current understanding encourages us to recognize all addiction, alcohol included, as a chronic medical problem no different than cancer, asthma, diabetes or seizure disorder. As such, addiction to alcohol and chronic alcoholism constitute disease. This perception change regarding addiction is apparent in new policies regarding the reimbursement of medical services for substance abuse, including chronic alcoholism. Under the Affordable Care Act, the coverage insurers must offer persons with a substance use disorder will be comparable to the coverage provided for other chronic illnesses such as hypertension, diabetes and asthma. It lists substance abuse disorders as one of the 10 elements of essential health benefits. 5 The National Institute on Alcohol Abuse and Alcoholism (NIAAA) has published recommendations on how much drinking is too much. For healthy men under 65, the limit of low-risk drinking is defined as no more than four drinks in a day (and not within a two-hour period) or 14 in a week. Healthy women of all ages and healthy men older than 65 are advised to drink no more than three drinks in a day (and not within a two-hour period) and no more than seven in a week. Gender and age differences in volume of distribution and concentrations of alcohol dehydrogenase in the liver and gastrointestinal tract account for the differences in recommendations. The NIAAA defines binge drinking (which should be avoided) as a pattern of alcohol consumption that results in a blood alcohol level over the legal limit of 0.08 g/dL, which for the average male is the result of more than four drinks in two hours (three drinks for the average female). 6 November 9 – 13, 2014 music city ceNter | Nashville, tN EMSWorldExpo.com | #EMSWorldExpo ExpEct morE. GEt morE… Education The largest EMS conference in North America, EMS World Expo offers superior and affordable education and learning opportunities to EMS providers at all levels, including: • 120+ CEU-certifed sessions led by top industry experts • Networking – connect and share solutions • Mobile Integrated Healthcare Summit • World Trauma Symposium Attend the conference that delivers MORE. Register today at EMSWorldExpo.com. EMSWORLD.com | APRIL 2014 45 EMS_44-51_CEArticle,Index0414.indd 45 3/14/14 8:55 AM