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Flashcards in Alcohol Deck (26):
1

Alcohol intoxication (A, B, C 6, D)

A. Recent use of alcohol
B. Problem behaviour/psychological disturbances develop shortly after ingestion
C. Presence of one or more
a. Slurred speech
b. Incoordination
c. Nystagmus
d. Unsteady gait
e. Impaired attention
f. Coma/stupor
D. Not due to other substance/other medical condition

2

Alcohol withdrawal (A, B 8, C, D)

A. Cessation of heavy alcohol use
B. Presence of two or more
a. Autonomic hyper-reactivity
b. Hand tremor
c. Nausea/vomiting
d. Insomnia
e. Auditory/tactile hallucinations
f. Psychomotor agitation
g. Anxiety
h. Tonic-clonic seizures
C. Cause clinically significant impairment
D. Not due to other substance/medical condition

3

Social complications of alcohol use

Love
Livelihood
Law
Homelessness
Financial
Absenteeism, poor work performance

4

Nervous system complications

Alcohol intoxication/withdrawal
Dementia
Cerebellar degeneration
Hemorrhagic stroke
Neuropathy
Wernickes/Korsakoffs

5

Gastrointestinal complications

Gastritis/ulcers
Hepatitis/Chronic liver
Chronic/acute pancreatitis
Cancer: oro/larynx, esophageal, hepatic

6

Cardiovascular system complications

Hypertension
IHD
Arrythmias
Cardiomyopathy

7

Metabolic/endocrine complications

Hypoglycemia
Hyponatremia
Hyperlipids/TAG
Hypomagnesium

8

Hematological complications

Red cell macrocytosis
Anaemia
Neutropenia
Thrombocytopenia

9

MSK, reproductive and other complications

Acute/chronic myopathy
Osteoporosis
IUGR/FAS
Impotence, erectile dysfunction
Trauma, fracture, violence

10

Wernicke's triad

Delirium
Opthalmoplegia
Ataxia

11

Etiology / risk factors of alcohol dependance

Genetic
+With family history
Positive reinforcement
Negative reinforcement
Modelling behaviour
Psychiatric illness coexisting
Antisocial and borderline + risk->attempts to self medicate, maladaptive coping, lack support, impulsivity
Social and cultural factors influincing acceptability
Particular occupation, unskilled and unemployed

12

General assessment

General Assessment
• When was your last drink?
• Do you have to drink more to get the same effect?
• Do you get shaky or nauseous when you stop drinking?
• Have you ever had a withdrawal seizure?
• How much time and effort do you put into obtaining alcohol?
• Has your drinking affected your ability to work, go to school, or have relationships?
• Have you suffered any legal consequences?
• Has your drinking caused any medical problems?

13

Stages of alcohol withdrawal

ƒƒ stage 1 (onset 12-18 h after last drink): “the shakes” tremor, sweating, agitation, anorexia,
cramps, diarrhea, sleep disturbance
ƒƒ stage 2 (onset 7-38 h): alcohol withdrawal seizures, usually tonic-clonic, nonfocal and brief
ƒƒ stage 3 (onset 48 h): visual, auditory, olfactory or tactile hallucinations
ƒƒ stage 4 (onset 3-5 d): delirium tremens, confusion, delusions, hallucinations, agitation,
tremors, autonomic hyperactivity (fever, tachycardia, hypertension)

14

Investigations in withdrawal

None required for diagnosis
FBC, UEC, LFTs, glucose->to exclude hypoglycemia, electrolyte, infections associated with alcohol abuse.
CT/CXR may be used to exclude infection, bleeding that may mimic alcohol withdrawal

15

Management of withdrawal

Supportive care: information, monitoring, reassurance, low stimulus, fluids/nutrition
Consider admission->cute, high risk of seizures, delirium tremens, smoking (use nicotine replacement)

If medication required
1. diazepam 20 mg orally, every 2 hours until symptoms subside, usually 60 mg required. Should not go >100mg, or for >3-5 days
AND
1. Before glucose, thiamine 300 mg IM or IV, daily for 3 to 5 days then thiamine 300 mg orally, daily for several weeks

If antipsychotic required
1. Haloperidol 0.5-2mg PO, every 2 hours (max 10mg/day
1. Benztropine 1-2mg PO if EPSE

16

Pathophysiology of alcohol use disorder

1. The pleasurable and stimulant effects-> dopaminergic pathway projecting from the ventral tegmental area to the nucleus accumbens.
2. Repeated, excessive alcohol ingestion sensitises this
3. Long-term exposure to alcohol causes adaptive changes -->down-regulation of inhibitory neuronal gamma-aminobutyric acid receptors, up-regulation of excitatory glutamate receptors, and increased central norepinephrine (noradrenaline) activity.
4. Discontinuation of alcohol ingestion leaves this excitatory state unopposed-> hyperactivity and dysfunction that characterise alcohol withdrawal.
5. Patients with alcohol-use disorder often experience craving, defined as the conscious desire or urge to drink alcohol.
6. Craving has been linked to dopaminergic, serotonergic, and opioid systems that mediate positive reinforcement, and to the gamma-aminobutyric acid, glutamatergic, and noradrenergic systems that mediate withdrawal.
7. Long-term use of alcohol is also proposed to enhance corticotrophin-releasing factor, neuropeptide Y, and other stress-producing neurotransmitters and hormones, so that continued alcohol use becomes necessary to relieve chronic stress and dysphoria.

17

What is used to assess withdrawal status

CIWA-Ar
Nausea and vomiting
Tremor
Paroxysmal sweats
Anxiety
Tactile
Auditory
Visual
Headache
Agitation
Orientation and clouding of sensorium

18

Management of dependance

1. Non-pharmacological
->Psychotherapy: motivational enhancement therapy
CBT, marital and family therapy
->Behaviour therapy: contingency management
->supportive services: counselling, detoxifocation
->Inpatient programs
2. Pharmacological
->Naltrexone
->Disulfuram
->Acamprosate

19

Naltrexone

50-100 mg orally once daily for 12-16 weeks; 380 mg intramuscularly once monthly for 6 months
Opioid antagonist
Family history
++Alcohol craving
May precipitate opioid withdrawal- need to be opioid free for several days

20

Acamprosate

666 mg orally three times daily for 12-16 weeks
Stabilises GABA and glutamate
Maintenance for abstinence
++For those who have stopped drinking
Decreases risk of relapse

21

Disulfuram

500 mg orally once daily for 1 week initially, followed by 250 mg once daily
Inhibits metabolism= +acetaldehyde
Flushing, nausea, diarrhea, tachyC, hypotension
Morbidity and mortality

22

Define delirium tremens

A delirium characterized by disorientation, fluctuation
in the level of consciousness, elevated vital signs, and tremors as the result of an abrupt reduction in or cessation of heavy alcohol use that has lasted for a
prolonged period of time.

23

Define korsakoff's

Not actually a psychotic state but
amnesia, both anterograde and retrograde amnesia, with confabulation that develops after chronic alcohol use. It is usually irreversible and is also caused by a thiamine deficiency.

24

Define wernickes

An acute, usually reversible, encephalopathy resulting
from a thiamine deficiency and characterized by the triad of delirium, ophthalmoplegia (typically sixth nerve), and ataxia.

25

In a patient withdrawing from alcohol with evidence of ++liver dysfunction, which benzodiazepine may be better suited and why

Lorazepam->less dependant on liver function for metabolism

26

AUDIT-C

• “How often do you have a drink containing alcohol?”—0 points for never,
1 point for monthly or less, 2 points for 2 to 4 times/month, 3 points for 2 to
3 times/week, 4 points for 4 days/week or more.
• “How many drinks containing alcohol do you have on a typical day when
you are drinking?”—0 points for not drinking, 1 point for 1 to 4 drinks,
2 points for 5 to 6 drinks, 3 points for 7 to 9 drinks, 4 points for 10 or more
drinks.
• “How often do you have 6 or more drinks on one occasion?”—0 points for
never, 1 point for less than monthly, 2 points for monthly, 3 points for
weekly, 4 points for daily or almost daily.