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  1. 1. Alcoholism
  2. 2. Winemaking Tradition Requiring the Fermentation of the Sugar in Grapes with Yeast to Form Alcohol
  3. 3. Engraving of ‘Gin Lane’ by William Hogarth (1697-1764) showing the popular opinion that the ‘lower classes’ drank gin and got drunk.
  4. 4. <ul><li>In the 18 months since the US invaded Iraq, over 1,000 American military personnel have been killed. Make you think twice about a military career? </li></ul><ul><li>Every academic year 1,400 American college students die from alcohol-related unintentional injuries, and another 500,000 are injured? Make you think twice about using alcohol? Or Going to college? </li></ul>
  5. 5. What is Alcohol? <ul><li>Ethyl Alcohol (Grain Alcohol) </li></ul><ul><ul><li>Booze, hooch, juice, brew </li></ul></ul><ul><ul><li>Used in medicine and beverages </li></ul></ul><ul><ul><li>Colorless, mixes with water, solvent </li></ul></ul><ul><ul><li>Product of sugar fermentation by yeast </li></ul></ul><ul><ul><li>Many cough & mouthwash contain up to 25% or 50 proof with antihistamines! </li></ul></ul><ul><ul><ul><li>NyQuil (25% etoh) Listerine (26.9%) </li></ul></ul></ul><ul><ul><ul><li>Formula 44D (20% etoh) Cepacol (14.5%) </li></ul></ul></ul>
  6. 6. Other Alcohols <ul><li>Methyl alcohol </li></ul><ul><li>(wood alcohol or antifreeze) </li></ul><ul><li>Isopropyl alcohol </li></ul><ul><li>(rubbing alcohol) </li></ul><ul><li>Butyl alcohol </li></ul><ul><li>Amyl alcohol </li></ul><ul><li>Very toxic when taken orally! </li></ul>
  7. 7. Ethyl Alcohols’ Local Effect <ul><li>Denatures proteins by precipitation and dehydration </li></ul><ul><li>Basis for use topically: </li></ul><ul><ul><li>Germicide </li></ul></ul><ul><ul><li>Irritant </li></ul></ul><ul><ul><li>Astringent </li></ul></ul><ul><li>Injection </li></ul><ul><ul><li>Pain, sloughing of tissues, nerve damage and anesthesia </li></ul></ul>
  8. 8. Ethyl Alcohol’s Overview Effect <ul><li>CNS depressant </li></ul><ul><ul><li>Appears to be a stimulant from the depression of the higher faculties of the brain and represents the loss of inhibitions </li></ul></ul><ul><ul><li>Decreases mental & physical ability </li></ul></ul><ul><ul><li>Given amounts affect individuals differently </li></ul></ul><ul><li>Excess consumption will cause bodily damage </li></ul><ul><ul><li>Has calories </li></ul></ul><ul><li>Time is the way to sober up </li></ul>
  9. 9. Systemic Effects CNS <ul><li>Interferes with nerve transmission at synapses </li></ul><ul><li>Progressive </li></ul><ul><li>Variable </li></ul><ul><ul><li>Size </li></ul></ul><ul><ul><li>Tolerance </li></ul></ul><ul><ul><li>Outside stimuli </li></ul></ul>
  10. 10. CNS Progressive Effects Death 410 + Lossbladder,dif breath, slowHR Cc,fb,cere,bs, entire brain Unconsci, coma, death poss 310-400 Slurred speech, blance, temp Cc,fb,cere, brainstem Aggression, stupor, depress 210-300 Reason, obnox, perceptions Cc,fb, cerebellum Mood swing, sad anger, mania 110-200 Fine coordinat, Visual tracking Cc and forebrain Pleasure, numb feelings, sleep 60-100 Alertness Judgement Cerebral Cortex Relax, sense of wellness, loss of inhibition 10-50 Impaired Brain Changes BAC (mg%)
  11. 11. Central Nervous System <ul><li>Acute Brain Damage </li></ul><ul><li>Alcohol Induced Brain Damage </li></ul><ul><li>Chronic Brain Damage </li></ul><ul><ul><li>Atrophy </li></ul></ul><ul><ul><li>Dementia </li></ul></ul><ul><ul><li>Nutritional Deficit Damage </li></ul></ul><ul><ul><li>Encephalopathy </li></ul></ul>
  12. 12. Alcohol Induced Brain Damage
  13. 13. CV GIT <ul><li>Dilation blood vessels </li></ul><ul><ul><li>Heat loss </li></ul></ul><ul><ul><li>Increase Pulse </li></ul></ul><ul><ul><li>Lower BP </li></ul></ul><ul><li>Chronic Use </li></ul><ul><ul><li>Cardiomyopathy </li></ul></ul><ul><ul><li>HTN, dysrhythmias </li></ul></ul><ul><ul><li>MI (J-curve) </li></ul></ul><ul><li>Stimulate GI acid </li></ul><ul><ul><li>Dissolves mucosal lining </li></ul></ul><ul><ul><li>Hemorrhagic lesions </li></ul></ul><ul><li>Chronic Use </li></ul><ul><ul><li>Pancreatitis </li></ul></ul><ul><ul><li>Diabetes or reactive hypoglycemia </li></ul></ul><ul><ul><li>Hepatic cellular damage </li></ul></ul><ul><ul><ul><li>Fibrosis & scarring </li></ul></ul></ul><ul><ul><ul><li>Cirrhosis & hepatitis </li></ul></ul></ul><ul><ul><li>Nutritional Deficit </li></ul></ul>
  14. 14. Renal Liver <ul><li>Increase urine due to increase fluid! </li></ul><ul><li>Acts as a diuretic </li></ul><ul><ul><li>Inhibits ADH </li></ul></ul><ul><li>Large chronic use </li></ul><ul><ul><li>Renal damage </li></ul></ul><ul><li>Liver Failure </li></ul><ul><ul><li>Leading cause is alcoholism </li></ul></ul><ul><ul><li>Cirrhosis, Cancer </li></ul></ul><ul><ul><li>Alcoholic Hepatitis </li></ul></ul><ul><li>Liver Transplant </li></ul><ul><ul><li>10% on recovering alcoholics </li></ul></ul><ul><ul><li>Non renewable resource </li></ul></ul>
  15. 15. Effect of Chronic EtOH on the Liver Healthy Fatty Cirrhotic
  16. 16. Pharmacokinetics of Ethanol <ul><li>Administration and absorption </li></ul><ul><ul><li>Oral & does not require digestion </li></ul></ul><ul><ul><ul><li>80% absorption from upper intestine </li></ul></ul></ul><ul><ul><ul><ul><li>Rate limiting factor is stomach emptying </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Total absorption is unaffected by food </li></ul></ul></ul></ul><ul><ul><li>Both water and fat soluble, distributes to every tissue </li></ul></ul><ul><ul><ul><li>90%+ access to all body compartments </li></ul></ul></ul>
  17. 17. Overview Metabolism of Alcohol <ul><li>Alcohol is converted by alcohol dehydrogenase to acetaldehyde </li></ul><ul><li>Acetaldehyde is converted by aldehyde dehydrogenase to acetic acid then to CO2 and water </li></ul>
  18. 18. Metabolism and Excretion <ul><li>Liver Metabolism </li></ul><ul><ul><li>95% of alcohol is metabolized by alcohol dehydrogenase enzyme and CYP450 </li></ul></ul><ul><ul><li>85% of that metabolism occurs in the liver </li></ul></ul><ul><ul><li>Balance eliminated via lungs and kidneys </li></ul></ul><ul><ul><li>All women, alcoholic or not, have 60% less stomach alcohol dehydrogenase than men </li></ul></ul><ul><ul><li>Women appear to be even more vulnerable than men to intoxication and chronic effects </li></ul></ul>
  19. 19. Pharmacodynamics <ul><li>Inhibits glutamate release and action at the receptors </li></ul><ul><ul><li>Increase glutamate release during withdrawal is excitotoxic </li></ul></ul><ul><li>Alcohol is a GABA & Dopamine agonist (stimulator!) </li></ul><ul><ul><li>Result is super sized combo of DA positive & GABA negative reinforcement </li></ul></ul>
  20. 20. French Paradox? <ul><li>CV benefits from 1 glass of wine/day </li></ul><ul><li>Disappear at equiv. 3 glasses/day </li></ul><ul><li>Same benefits </li></ul><ul><ul><li>6 glasses grape juice </li></ul></ul><ul><ul><li>Flavinoids not Etoh </li></ul></ul><ul><li>CV disease </li></ul><ul><ul><li>Cumulative </li></ul></ul><ul><ul><li>Multiple </li></ul></ul><ul><ul><li>factors </li></ul></ul><ul><ul><li>Prior to </li></ul></ul><ul><ul><li>1960s French diet </li></ul></ul><ul><ul><li>lower in saturated </li></ul></ul><ul><ul><li>fats than American </li></ul></ul><ul><ul><li>diet </li></ul></ul>
  21. 21. Selective Significant Drug Interactions with Alcohol GI bleeding Additive ASA NSAIDs n/v/flushing, HA, sweating, inc HR hypotension, Accumulation of acetaldehyde Disulfiram metronidazole Enhanced CNS depressant effects Additive Antihistamines, antidepressants, opioids, sed-hyp, antianxiety, antipsychotic drugs Possible Effect Mechanism Substances
  22. 22. Fetal Alcohol Syndrome <ul><li>Teratogenic </li></ul><ul><li>Mental Retardation </li></ul><ul><li>Low Birth Weight </li></ul><ul><li>Neurological </li></ul>
  23. 23. Craniofacial Malformations Normal Exposed to Alcohol
  24. 24. Symptoms of Alcohol Dependence <ul><li>Job performance </li></ul><ul><li>Behavioral </li></ul><ul><ul><li>Blackouts </li></ul></ul><ul><ul><li>Depression </li></ul></ul><ul><ul><li>Insomnia </li></ul></ul><ul><ul><li>Disappearing </li></ul></ul><ul><ul><li>Frequent </li></ul></ul><ul><ul><li>Bathroom breaks </li></ul></ul><ul><li>Sleeping a lot </li></ul><ul><li>Emotional flares </li></ul><ul><li>Slurred speech </li></ul><ul><li>Use of mints & mouthwash </li></ul>
  25. 25. Alcohol Withdrawal Symptoms <ul><li>Acute Infrequent Ingestion </li></ul><ul><ul><li>Hangover </li></ul></ul><ul><ul><ul><li>HA, n/v, malaise </li></ul></ul></ul><ul><li>Chronic Ingestion 48-72 hours into withdrawal </li></ul><ul><ul><li>Mental disturbances </li></ul></ul><ul><ul><ul><li>Anxious, confusion </li></ul></ul></ul><ul><ul><ul><li>Nightmares, sweats </li></ul></ul></ul><ul><ul><ul><li>Hallucinations, fear </li></ul></ul></ul><ul><li>Perception Distortions </li></ul><ul><ul><li>Spinning, floor moves </li></ul></ul><ul><ul><li>Injury from falls </li></ul></ul><ul><li>Delirium Tremens (DTs) </li></ul><ul><ul><li>Tachycardia. Increased temperature </li></ul></ul><ul><ul><li>Convulsions </li></ul></ul><ul><ul><li>Tonic-Clonic Activity </li></ul></ul><ul><ul><li>Tremors </li></ul></ul>
  26. 26. Avenues of Treatment Non-Pharmacologic <ul><li>Life long disease </li></ul><ul><ul><li>Motivated client </li></ul></ul><ul><ul><li>Complete abstinence </li></ul></ul><ul><ul><ul><li>Controlled Drinking? </li></ul></ul></ul><ul><ul><li>Behavioral and psychosocial support </li></ul></ul><ul><ul><ul><li>AA mainstay of treatment </li></ul></ul></ul><ul><ul><li>Concurrent diseases (Co-morbidity) </li></ul></ul><ul><ul><ul><li>Depression, anxiety </li></ul></ul></ul>
  27. 27. Pharmacologic Support <ul><li>Aversion Therapy </li></ul><ul><ul><li>Works by making patients sick with nausea and vomiting if they drink alcohol. </li></ul></ul><ul><ul><li>Disulfiram (Antabuse) </li></ul></ul>
  28. 28. Agents <ul><li>Campral (acamprosate) Glutamate agonist </li></ul><ul><li>Antabuse (disulfiram) Aversion therapy </li></ul><ul><li>ReVia (naltrexone) Opiate antagonist </li></ul><ul><li>Topamax (topiramate) Craving reduction </li></ul><ul><li>Benzodiazepines for withdrawal </li></ul><ul><li>Antidepressants for depression </li></ul><ul><li>Antipsychotics for hallucinations dangerous </li></ul>
  29. 29. Kindling Model