Alcohol

Question 1

Define alcoholic:

Answer 1

primary chronic disease characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite adverse consequences, and distortions in thinking

Question 2

Define: dependence

Answer 2

needs 3 of 7 conditions over 12 months

• tolerance
• withdrawal symptoms
• ingestion in larger amounts
• persistent desire
• expenditure of increase time in drinking/recovering
• abandoning social/work activities
• continued ingestion despite problem

Question 3

What does the DSM-5 state about alcohol abuse?

Answer 3

integrates alcohol abuse and alcohol dependence into alcohol use disorder (AUD)

• mild, moderate or severe subclassifications
• > 6 = severe

Question 4

Is alcohol ever good for you?

Answer 4

Definitive data lacks proof of the cardiovascular benefits of alcohol whereas the harms are well established

Question 5

What is 1 unit of alcohol?

Answer 5

10ml ethanol = 8 g ethanol

Question 6

How is alcohol absorbed?

Answer 6

duodenum-jejunum over 80%
process of simple diffusion
rate is concentration dependent and related to stomach emptying

Question 7

How is alcohol distributed following absorption?

Answer 7

rapidly distributed - rich blood supply = faster effect
crosses BBB easily
Volume of distribution equal to total body water - 0.6L/kg
differences between men and women - higher effect on women
fatter people high relative blood concentration - reason affects women more

Question 8

How is alcohol metabolised?

Answer 8

98% by ADH to acetylaldehyde and then by ALDH to acetate

• acetylaldehyde is toxic and causes nausea, flushing and headaches
• there are genetic variations in ALDH
• ADH is rate limiting step

Question 9

What is the normal clearance rate of alcohol?

Answer 9

6g/hour

Question 10

How is alcohol excreted?

Answer 10

small amounts not metabolised and excreted unchanged

- in urine and breath - useful for detection

Question 11

What is the pharmacological effect of alcohol?

Answer 11

Central nervous system depressant - (apparent stimulatory effects are due to depression of inhibitory control mechanisms in the brain)
GABA-A potentiation
NMDA antagonist - causing glutamate inhibition
effects on serotonin, opioid and dopaminergic neurotransmission (reward centres)

Question 12

What is the legal driving limit in England and wales?

Answer 12

80mg alcohol /100ml blood
35 micrograms alcohol / 100ml breath
107mg alcohol / 100ml urine

Question 13

What effect does alcohol have on CNS drugs ?

Answer 13

increased drowsiness/sedation

e.g. SSRIs, benzodiazepine, antihistamines

Question 14

What effect does alcohol have on antihypertensives/cardiovascular drugs?

Answer 14

enhanced hypotensive effects

Question 15

What effect does alcohol have on warfarin?

Answer 15

major changes in consumption of alcohol may affect anticoag control with coumarins

Question 16

What effect does alcohol have on metronidazole / ketoconazole?

Answer 16

inhibits ALDH - gives you an awful hangover effect - like a disulfiram like reaction

Question 17

What does disulfiram do?

Answer 17

certain drugs inhibit ALDH causing accumulation of acetylaldehyde
- used as an aversion therapy - help alcoholics stop drinking

Question 18

What are the medical uses of alcohol?

Answer 18

local use - bacteriocidal swabs/gels
used in pharmaceutical solutions - awareness of their use in children
methanol/ethylene glycol poisoning - competitively inhibiting ADH - now fomepizole is more commonly used

Question 19

What are the main medical / psychiatric problems associated with alcohol?

Answer 19

acute alcohol intoxication
alcohol withdrawal reactions - inc delirium tremens
chronic alcoholism
contributes to obesity epidemic

Question 20

What are the characteristic features of acute alcohol intoxication and common causes of death?

Answer 20

AAI associated with violence, accidents, injuries, sexual victimisation and suicides
Common causes of death - aspiration from vomiting when reduces GCS or trauma
Beware of associated hypoglycaemia (esp. in children)

Question 21

What is binge drinking classified as?

Answer 21

> 8 in males and >6 in females at once

Question 22

What does the CAGE questionnaire stand for?

Answer 22

Cut down amount of drinking 
Annoyed by criticism 
Guilty feelings about drinking 
Eye opener in the morning 
- this questionnaire is not as sensitive in white females or pregnancy

Question 23

What are a couple of other screening tests?

Answer 23

Fast and audit

Question 24

When trying to diagnose an alcohol problem what physical examinations are carried out?

Answer 24

usually no findings
Signs of chronic liver disease
parotid enlargement 
rhinophyma 
peripheral neuropathy
signs of withdrawal

Question 25

When trying to diagnose an alcohol problem what laboratory tests are carried out?

Answer 25

FBC - macrocytosis in the absence of anaemia can be due to alcohol U&Es - low urea LFTs - raised transaminases Gamma GT - elevated - if associated with liver pathology INR - prolonged

Question 26

What are the alcohol withdrawal symptoms at 6-12 hours?

Answer 26

``` insomnia tremulousness anxiety GI upset headache diaphoresis palpatations anorexia ```

Question 27

What are the alcohol withdrawal symptoms at 12-24 hours?

Answer 27

alcoholic hallucinosis: visual, auditory or tactile hallucinations

Question 28

What are the alcohol withdrawal symptoms at 24-48 hours?

Answer 28

generalised tonic clonic seizures

Question 29

What are the alcohol withdrawal symptoms at 48-72 hours?

Answer 29

``` delirium tremens halluncinations disorientation tachycardia increase BP mild fever agitation diaphoresis ```

Question 30

What are the principles of managing alcohol withdrawal?

Answer 30

ABC - resus Prevention/ treatment of encephalopathy Prevention/treatment of withdrawal Prevention/treatment of complications

Question 31

What is involved in the prevention/ treatment of encephalopathy?

Answer 31

vitamins-thiamine and other B vitamins Severe deficiency states (e.g. wernickes) best treated by parenteral therapy High potency vitamin B complex (parabrinex)- contains high dose thiamine (B1), riboflavin (B2), pyridoxine (B6), nicotinamide and vit C 2-3 pairs of ampoules every 8 hours SE: potentially serious allergic reaction Followed by.. - oral thiamine 200-300 mg daily - and vit B compound strong 2 tabs TDS

Question 32

What is involved in the prevention/ treatment of alcohol withdrawal?

Answer 32

Community / hosp setting - benzodiazepines treatment of symptoms / prevention of seizures reactive- prescribe according to symptoms (clinical institute withdrawal assessment for alcohol (CIWA)) expectant - prescribe fixed dose

Question 33

What is involved in the prevention/ treatment of complications and abstinence?

Answer 33

associated psychiatric problems social interventions - AA, aquarius pharmacological maintence of abstinence - acamprosate - stabilises glutamate and GABA systems = reduces cravings, anxiety and insomnia - naltrexone - opioid antagonist - helpful as an adjunct to alcohol dependence after withdrawal treated, reduce rate of relapse - nalmefene - opioid receptor modulator - reduction of alcohol consumption - take 1-2 hours before drinking - disulfiram - inhibits ALDH leading to flushing, sweating and nausea