Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Alcoholism


Related Terms

  • Alcohol Abuse
  • Alcohol Addiction
  • Alcohol Dependence
  • Alcohol Dependence Syndrome

Differential Diagnosis

Specialists

  • Addiction Psychiatrist
  • Cardiovascular Internist
  • Clinical Psychologist
  • Endocrinologist
  • Gastroenterologist
  • Neurologist
  • Occupational Therapist
  • Physical Therapist
  • Psychiatrist

Comorbid Conditions

Factors Influencing Duration

The length of disability is influenced by the duration and severity of alcohol dependence, the presence or absence of organ damage, any comorbid mental illness, other substance abuse, the individual's social support system, the appropriateness of treatment, the individual's compliance with treatment, and the adequacy of ongoing care.

Medical Codes

ICD-9-CM:
303 - Alcohol Dependence Syndrome
303.9 - Alcohol Dependence, Other and Unspecified; Chronic Alcoholism; Dipsomania
303.90 - Alcohol Dependence, Other and Unspecified; Unspecified
303.91 - Alcohol Dependence, Other and Unspecified; Continuous
303.92 - Alcohol Dependence, Other and Unspecified; Episodic
303.93 - Alcohol Dependence, Other and Unspecified; in Remission

Overview

Alcoholism or alcohol dependence occurs when an individual continues to use alcohol despite significant alcohol-related physical, emotional, relational, legal, or occupational problems. There is a strong need or compulsion to drink, and it becomes difficult for individuals to stop drinking once they have begun. Repeated use results in the need for increased amounts over time in order to achieve intoxication (tolerance). Repeated heavy use also results in physiological and cognitive changes, with decreasing blood and brain tissue concentration of alcohol known as withdrawal. Failure to abstain from using alcohol despite having difficulties associated with its use is referred to as compulsivity.

Roughly 40% to 60% of the chance that someone may develop alcohol dependence can be explained by genetic factors. Close relatives of alcoholics are 3 to 4 times more likely to become alcoholics themselves (DSM-IV-TR). Other risk factors may include cultural attitudes toward drinking and intoxication, the availability of alcohol, acquired personal experiences, and stress. There seems to be an association between family history of depression and alcoholism.

Incidence and Prevalence: According to the National Longitudinal Alcohol Epidemiologic Study, one-fifth of hospital patients were alcoholics. Roughly 100,000 people yearly die from alcoholism or alcohol-related accidents. Among the causes of preventable death in the US, alcoholism comes in at number three, after smoking and obesity; 6% of people in outpatient offices were alcohol dependent or abusers, according to the World Health Organization (Thompson).

Source: Medical Disability Advisor



Causation and Known Risk Factors

Poor urban-dwelling males, as well as those with little formal education, are at increased risk to abuse alcohol. Hispanics are more or just as likely to abuse alcohol as whites, but blacks are less likely than whites to abuse alcohol. According to a national comorbidity study, males are 2.5 times more likely to abuse alcohol than females. Alcohol abuse decreases with age (Thompson).

Some ethnic groups, such as Asians, show low prevalence rates of alcoholism related to a deficiency of an enzyme used in the metabolism of alcohol.

Source: Medical Disability Advisor



Diagnosis

History: The diagnosis is based on criteria listed in the DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision). There is a history of regular, often daily, alcohol ingestion and a period of time with withdrawal symptoms occurring within 4 to 12 hours of the last drink.

Diagnostic criteria include a need for markedly increased amounts of alcohol to achieve intoxication (tolerance); diminished effects with continued use of the same amount of alcohol (tolerance); symptoms of withdrawal such as tremors, increased blood pressure or heart rate, cravings, sweating, or fever; persistent unsuccessful attempts to quit or control alcohol intake; a great deal of time spent in activities related to the use of or recovery from the use of alcohol; social, occupational, recreational, or relational activities given up for the sake of alcohol use; and continued alcohol use despite knowledge of recurrent physical or psychological problems related to its use.

Diagnosis depends on the individual demonstrating at least three or more of these criteria at any time in the same 12-month period. Other symptoms noted on the history may include disturbing memory lapses (blackouts), poor appetite, heartburn, nausea, gas, seizures, decreased sex drive, difficulty sleeping, and seeing or hearing things that are not really there (hallucinations), mostly during withdrawal periods (detoxification periods, "DTs"). The most common hallucinations are visual and involve bugs and other animals.

Physical exam: The exam may reveal signs of withdrawal such as tremors, sweating, increased blood pressure, or increased heart rate. Examination by gently pressing on the abdomen (palpation) may detect an enlarged liver or a small, hard liver. The palms may be red (palmar erythema). A mental status exam may demonstrate that the individual is confused or disoriented. Neurological examination may show impaired gait and balance (cerebellar ataxia) or decreased vibration sense in the hands and feet (peripheral neuropathy).

Tests: An elevated blood glutamyl transferase is a good indicator for alcoholism. An elevated blood alcohol level without signs of intoxication indicates alcohol tolerance. Other blood tests can detect the effects of alcohol on the liver and bone marrow by showing elevated liver enzymes, high blood lipids, and anemia with large red blood cells (macrocytosis). Psychological testing may also be done because it can offer useful insights into underlying comorbid psychopathology in the individual.

Source: Medical Disability Advisor



Treatment

Recovery from alcoholism occurs in four phases. The first phase is an acute detoxification phase that focuses on alleviating symptoms of physiological withdrawal and typically lasts for 3 to 5 days. The second phase is a 1 month period of abstinence during which the individual focuses on changing behaviors. The third phase is an early remission phase that can last up to 12 months. The fourth phase is a sustained remission phase that lasts as long as the individual abstains from alcohol intake or from meeting the criteria for alcoholism.

Treatment during the acute phase requires close observation for at least 72 to 96 hours for the emergence of withdrawal symptoms. Medication therapy in the acute phase includes the use of benzodiazepines to decrease tremors and reduce or prevent increased blood pressure and heart rate, in addition to medications for other symptoms (e.g., diarrhea or muscle aches). Folic acid, thiamine, and vitamin B12 are used to replace vitamin deficiencies. Clonidine, phenothiazines, beta-blockers, and anticonvulsants may be combined with benzodiazepines but not used as lone agents. Some individuals may be admitted to a hospital or a specialized alcohol detoxification unit for the first few days of treatment, whereas others may be treated on an outpatient basis in a partial hospital or intensive outpatient program. Inpatient rehabilitation may be necessary for a period of time, especially if the individual's environment does not support sobriety and recovery.

Treatment for the 1 month abstinence and early remission phase may include education on the physical, emotional, and mental aspects of addiction and recovery; identification of stressors and stress management skills; improved coping skills; assertiveness training; and relaxation training. A narcotic antagonist such as naltrexone that diminishes the effects of alcohol or the drug Antabuse, which causes an individual to be intolerant of alcohol, can be used to help some individuals remain abstinent. In addition to professional treatment, many individuals join self-help groups like Alcoholics Anonymous (AA). The long-term support that self-help groups provide can be crucial in preventing relapse.

An alternative to AA is Rational Recovery, a self-help group based on cognitive rather than spiritual principles. Since rehabilitated alcoholics are in danger of relapsing from even a single drink, successful rehabilitation requires total abstinence that is usually accomplished "one day at a time." Marital counseling and family support are often needed for long-term stability and resolution of codependency problems. Attending Al-Anon and Alateen meetings can be helpful to the patient's relatives.

Source: Medical Disability Advisor



Prognosis

Many individuals respond to treatment and stay in remission from alcohol dependence for many years. However, other individuals experience periods of relapse, during which they resume alcohol intake after a period of remission and again meet the criteria for alcohol dependence. Other individuals are never able to abstain from alcohol intake and do not experience any periods of remission. The complications of alcoholism are serious, life-threatening, and potentially fatal, especially if untreated.

Individuals with personality disorders such as antisocial personality disorder can have prolonged or failed recovery. Abstinence for a 12-month period is an accomplishment less than 20% of alcoholics are able to attain; alcohol abuse will cease in up to 30% of patients indefinitely (Thompson).

The outcome is improved if the individual seeks treatment early in the disease process and has adequate social support systems in place. However, a significant number of individuals experience at least one relapse after treatment, and 20% or more may never seek help or comply with medication or therapy but manage to stay sober (DSM-IV-TR). Halfway houses or quarterly houses may be used when sober social support is not adequate, or is nonexistent.

Source: Medical Disability Advisor



Rehabilitation

Once acute withdrawal is over and the individual has successfully completed alcohol detoxification, rehabilitation begins during hospitalization or with frequent outpatient visits. It involves ongoing medical monitoring, nutritional therapy, moderate physical exercise, education about alcoholism, and introduction to a 12-step self-help support group.

In addition to substance abuse treatment and support groups, physical therapy may be helpful if the individual has chronic problems with gait and balance or has become deconditioned due to inactivity during the period of addiction and early recovery. Occupational therapy assists the individual in developing communication skills, identifying and matching personal skills and work habits to the workplace, and learning how non-alcohol-related participation in leisure activities contributes to overall health and well being. Supportive therapies include expressive therapies (art, music, or dance therapy), relaxation techniques, or breath therapy and may be helpful to decrease stress levels that can increase risk of relapse.

Source: Medical Disability Advisor



Complications

For someone who regularly drinks too much, sudden withdrawal of alcohol can lead to tremors, anxiety, agitation, hallucinations, grand mal seizures, or death. Excessive prolonged use of alcohol can damage the stomach lining (gastritis), esophagus (esophageal varices), liver (liver failure, cirrhosis), pancreas (pancreatitis), and heart (cardiomyopathy). Poor nutrition contributes to anemias and vitamin deficiencies. Alcoholism leads to increased risk of certain cancers involving the liver, esophagus, throat, and voicebox (larynx). Prolonged alcohol intake is toxic to the nervous system and can damage the nerves in the hands, lower legs, and feet (peripheral neuropathy). Brain function may be chronically impaired and can lead to short- and long-term memory impairment, disturbances of balance and coordination, or the loss of higher brain functions such as judgment, abstract thinking, and language.

The B vitamin thiamine is depleted in alcoholics. This deficiency can lead to a neurological disorder characterized by abnormalities in eye movements and loss of short-term memory (Wernicke-Korsakoff syndrome). Alcoholism can lead to the loss of relationships and employment, legal consequences such as arrests for "driving under the influence," motor vehicle accidents, violence, and suicide. Job performance and childcare or household responsibilities may decline or be neglected. Anxiety related to drinking or to withdrawal may lead to the abuse of anxiolytic medications or other mind-altering drugs. Heavy drinking during pregnancy can result in fetal alcohol syndrome, an incurable condition in the baby characterized by stunted growth, physical abnormalities, and mental retardation.

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Many employers have systems in place for individuals recovering from alcohol dependence disorders to return to work under special contracts or conditions. These conditions may provide guidelines for random testing of blood and urine levels of identified substances and provide work performance and substance abuse treatment guidelines for the recovering individual.

Temporary work accommodations may include reducing or eliminating activities where the safety of self or others is contingent upon a constant and/or high level of alertness, such as driving motor vehicles, operating complex machinery, or handling dangerous chemicals; introducing the individual to new or stressful situations gradually under individually appropriate supervision; allowing some flexibility in scheduling to attend therapy appointments (which normally should occur during employee's personal time); promoting planned, proactive management of identified problem areas; and offering timely feedback on job performance issues. It will be helpful if accommodations are documented in a written plan designed to promote timely and safe transition back to full work productivity. A shift change to day shift may be necessary for more adequate monitoring.

If individuals have chronic side effects of prolonged alcohol intake, such as cardiac, liver, or nervous system damage, they may need restriction to sedentary activities. Certain jobs, such as being a bartender, hostess, or entertainer, may involve exposure to alcohol and increase the risk of relapse.

Source: Medical Disability Advisor



Failure to Recover

If an individual fails to recover within the expected maximum duration period, the reader may wish to consider the following questions to better understand the specifics of an individual's medical case.

Regarding diagnosis:

  • Was diagnosis of alcoholism confirmed? Alcohol abuse? Alcohol dependence?
  • What was individual's drinking pattern?
  • What medical complications resulted?
  • Were any other chemical dependencies identified?
  • Was each one appropriately addressed?
  • Were all underlying conditions, physical and psychiatric, identified?
  • How do they affect treatment or prognosis?

Regarding treatment:

  • Was alcohol detoxification considered successful?
  • Have other medical complications and nutritional deficiencies received treatment?
  • If concurrent chemical abuse was also identified, is appropriate treatment being applied to each issue?
  • Are psychiatric illnesses complicating treatment? Are these illnesses being addressed in regard to overall treatment?
  • Is individual able to safely and consistently follow treatment regime?
  • Is individual receiving treatment on an inpatient or outpatient basis?
  • Would individual benefit from a more supervised, structured treatment plan or an in-house treatment program?

Regarding prognosis:

  • Does individual appear to be making appreciable progress within the current treatment modality?
  • How are current stresses being dealt with?
  • How were major stresses dealt with in the past?
  • If healthy and adaptive methods were used in the past, are they being used currently?
  • What is happening outside work that may be contributing to or worsening the problems experienced at work?
  • Is individual receiving the necessary tools, skills, and encouragement to move ahead with his or her life?
  • What are the individual's social supports? Does individual have a personal, accepting support system in place? Family? Friends? Church or other community affiliations? Are these being used?
  • Is individual involved in a local support group (AA or NA)?
  • Could the family benefit from education or support groups?

Source: Medical Disability Advisor



References

Cited

Frances, Allen, ed. Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR). 4th ed. Washington, DC: American Psychiatric Association, 2000.

Thompson, Warren. "Alcoholism." eMedicine. Ed. Denis F. Darko. 21 Sep. 2004. Medscape. 8 Sep. 2004 <http://emedicine.com/med/topic98.htm>.

Source: Medical Disability Advisor






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