Flashcards in Alcohol Deck (26)
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
d. Unsteady gait
e. Impaired attention
D. Not due to other substance/other medical condition
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
e. Auditory/tactile hallucinations
f. Psychomotor agitation
h. Tonic-clonic seizures
C. Cause clinically significant impairment
D. Not due to other substance/medical condition
Social complications of alcohol use
Absenteeism, poor work performance
Nervous system complications
Cancer: oro/larynx, esophageal, hepatic
Cardiovascular system complications
Red cell macrocytosis
MSK, reproductive and other complications
Impotence, erectile dysfunction
Trauma, fracture, violence
Etiology / risk factors of alcohol dependance
+With family history
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
• 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?
Stages of alcohol withdrawal
stage 1 (onset 12-18 h after last drink): “the shakes” tremor, sweating, agitation, anorexia,
cramps, diarrhea, sleep disturbance
stage 2 (onset 7-38 h): alcohol withdrawal seizures, usually tonic-clonic, nonfocal and brief
stage 3 (onset 48 h): visual, auditory, olfactory or tactile hallucinations
stage 4 (onset 3-5 d): delirium tremens, confusion, delusions, hallucinations, agitation,
tremors, autonomic hyperactivity (fever, tachycardia, hypertension)
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
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
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
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.
What is used to assess withdrawal status
Nausea and vomiting
Orientation and clouding of sensorium
Management of dependance
->Psychotherapy: motivational enhancement therapy
CBT, marital and family therapy
->Behaviour therapy: contingency management
->supportive services: counselling, detoxifocation
50-100 mg orally once daily for 12-16 weeks; 380 mg intramuscularly once monthly for 6 months
May precipitate opioid withdrawal- need to be opioid free for several days
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
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
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.
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.
An acute, usually reversible, encephalopathy resulting
from a thiamine deficiency and characterized by the triad of delirium, ophthalmoplegia (typically sixth nerve), and ataxia.
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