Alcohol and AlcoholismPRESENTER-DR. PRADIP KATWALMODERATOR-DR. THOMAS JOHN
WHY ALCOHOL ISA PUBLIC HEALTH Causal factor in more than 60CONCERN? major types of diseases and injuries Results in approximately 2.5 million deaths each year. 4% of all deaths worldwide are attributable to alcohol.World Health Organization (2008b). The global burden of disease: 2004update. Geneva (http://www.who.int/evidence/bod, accessed 28November 2010
HISTORY OF ALCOHOL Alcoholic beverages in the Indus valley civilization. These beverages were in use between 3000 BC - 2000 BC. Sura, a beverage brewed from rice meal, wheat, sugar cane, grapes, and other fruits, was popular among the warriors and the peasant population. Sura is considered to be a favorite drink of Indra.
Devotees drink traditional alcohol flowing from the mouth of a statue ofthe deity Swet Bhairav during the second day of the week long Indra Jatra festival in Nepal
When the pregnant woman gives birth to the child, the family membersserve best quality of aerakm ( Alcohol) or chhyang (Fermented liquor) toher. If the economic status is good, they serve warm alcohol mixed withone teaspoon of ghee.They believe it helps to restore the energy and as the drink makes herintoxicated it relives her from exhaustion.
Present scenarioA total of 1068 individuals successfully completed the study. According to DSM-IV, drinkers were classified as follows: No alcohol problem (n=562; 59.5%),alcohol abusers (n= 78; 8.3%) and alcohol dependent (n=304;32.2%). The prevalence of hazardous drinker was 67.1%
There were 55 subjects in the study. Half of them were between 35-45 years agegroup and one fourth among them were female. There were more than 88%physicians consuming alcohol for more than 10 years. One third used topreferred whisky as their favorites drink.
Alcohol are derivatives ofWhat is alcohol ? hydrocarbons One or more of the hydrogen atoms have been replace by a hydroxyl (- OH) functional group Ethyl alcohol - for which the more scientific name is ethanol - is the substance that we find in beverages. Formed through fermentation of a variety of products including grain such as corn, potato mashes, fruit juices, and beet and cane sugar molasses
ALCOHOL 10–15 g of Equivalent to 115 mL (4 oz) of ethanol nonfortified wine (a standard drink) 43 mL (1.5 oz) (a shot) whisky, gin, or vodka 340 mL (12 oz) of beer
PHYSIOLOGYAbsorption Rate of absorption is increasedmouth and Carbonatedesophagus (in beveragessmall amounts) Absence of stomach and proteins, large bowel (in fats, or modest carbohydrate amounts) s proximal Dilution of portion of the ethanol (20% small intestine by volume). (the major site).
Metabolism• Two pathways – Alcohol dehydrogenase – Microsomal ethanol oxidizing system
Breath analyser Between 2% and 10% of ethanol is excreted directly through the lungs, urine, or sweat. The concentration of the alcohol in the alveolar air is related to the concentration of the alcohol in the blood. As the alcohol in the alveolar air is exhaled, it can be detected by the breath alcohol testing device.
Do alcohol giveenergy? • Alcohol supplies calories (a drink contains 70–100 kcal), Devoid of nutrients such as minerals, proteins, and vitamins. Interfere with absorption of vitamins in the small intestine Decreases their storage in the liver
Alcohol on neurotransmitter systems neurotransmitt acute alcohol er intoxication withdrawal Gamma aminobutyri c acid (GABA) N-methyl-d- aspartate (NMDA) excitatory glutamate receptors
Behavioral EffectsEffects of Blood Alcohol Levels in the Absenceof ToleranceBlood Level, g/dL Usual Effect0.02 Decreased inhibitions, a slight feeling of intoxication0.08 Decrease in complex cognitive functions and motor performance0.20 Obvious slurred speech, motor incoordination, irritability, and poor judgment0.30 Light coma and depressed vital signs0.40 Death
Tolerance Metabolic or pharmacokinetic tolerance – 30% increase in the rate of hepatic ethanol metabolism Cellular or pharmacodynamic tolerance – neurochemical changes that maintain relatively normal physiologic functioning despite the presence of alcohol. Learned or behavioral tolerance – adapt their behavior so that they can function better than expected under influence of the drug
Cancer• Breast cancer 1.4-fold.• Oral and esophageal cancers approximately threefold• Rectal cancers by a factor of 1.5These consequences may result directly from cancer- promoting effects of alcohol and acetaldehyde or indirectly by interfering with immune homeostasis.
Hematopoietic System Increased red blood cell size (mean corpuscular volume) Folic acid deficiency. Decrease production of white blood cells Thrombocytopenia.
Definitions• Alcoholism - patients with alcohol problems• "... a primary chronic disease with genetic psychosocial and environmental factors ... often progressive and fatal ... characterized by impaired control over drinking, preoccupation with the drug alcohol, use of alcohol despite future consequences, and distortions of thinking most notably denial...." *National Council on Alcoholism and Drug Dependence and the American Society of Addiction Medicine
• Abstainers- – individuals who consume no alcohol• Low risk drinking – number of drinks consumed daily that places an adult at low risk for alcohol problems• At-risk drinking – a level of alcohol consumption that imparts health risksRisk drinking is defined as an average of 15 or more standarddrinks per week or 5 or more on an occasion for men and 8 ormore drinks weekly or 4 or more on an occasion for women andpeople older than 65 years of age.
Alcohol dependence“A cluster of behavioural, cognitive, and physiological phenomena thatdevelop after repeated alcohol use and that typically include a strongdesire to consumeDifficulties in controlling its use Persisting in its use despite harmful consequencesA higher priority given to alcohol use than to other activities andobligationsIncreased toleranceAnd sometimes a physical withdrawal state
Alcohol abuse • Alcohol abuse is defined as repetitive problems with alcohol in any one of four life areas – social – interpersonal – Legal – occupational • repeated use in hazardous situations such as driving while intoxicated in an individual who is not alcohol dependent.The criteria are based on the Diagnostic and Statistical Manual of Mental Disorders,fourth edition, text revision (DSM-IV-TR). The table is adapted from the DSM-IV-TRand information from the National Institute on Alcohol Abuse and Alcoholism.
Identification of the Alcoholic• Questions about alcohol problems• laboratory test• The two blood tests with 60% sensitivity and specificity for heavy alcohol consumption are – glutamyl transferase (GGT) (>35 U) – carbohydrate-deficient transferrin (CDT) (>20 U/L or >2.6%);• Other useful blood tests include high-normal MCVs (91 m3) and serum uric acid (>416 mol/L, or 7 mg/dL).
The Alcohol Use Disorders Identification Test(Audit)Item 5-Point Scale (Least to Most)1. How often do you have a drink Never (0) to 4+ per week (4)containing alcohol?2. How many drinks containing alcohol 1 or 2 (0) to 10+ (4)do you have on a typical day?3. How often do you have six or more Never (0) to daily or almost daily (4)drinks on one occasion?4. How often during the last year have Never (0) to daily or almost daily (4)you found that you were not able to stopdrinking once you had started?
5. How often during the last year Never (0) to daily or almost daily (4)have you failed to do what wasnormally expected from you becauseof drinking?6. How often during the last year have Never (0) to daily or almost daily (4)you needed a first drink in the morningto get yourself going after a heavydrinking session?7. How often during the last year have Never (0) to daily or almost daily (4)you had a feeling of guilt or remorseafter drinking?8. How often during the last year have Never (0) to daily or almost daily (4)you been unable to remember whathappened the night before because youhad been drinking?9. Have you or someone else been No (0) to yes, during the last year (4)injured as a result of your drinking?10. Has a relative, friend, doctor or No (0) to yes, during the last year (4)other health worker been concernedabout your drinking or suggested thatyou should cut down?
The Nepali version of AUDIT is a reliable and valid screening tool to identifyindividuals with alcohol use disorders in the Nepalese population. AUDITshowed a good capacity to discriminate dependent patients (with AUDIT≥11for both the gender) and hazardous drinkers (with AUDIT≥5 for males and≥4for females). For alcohol dependence/abuse the cut off values was≥9 for bothmales and females.
Acute Intoxication• Assess vital signs• Manage respiratory depression,• Cardiac arrhythmia• Blood pressure instability.• The possibility of intoxication with other drugs should be considered.• Aggressive behavior should be handled by offering reassurance but also by considering the possibility of a show of force with an intervention team.• If the aggressive behavior continues, relatively low doses of a short-acting benzodiazepine such as lorazepam (e.G., 1–2 mg PO or IV) may be used and can be repeated as needed• An alternative approach is to use an antipsychotic medication (e.G., 0.5–5 mg of haloperidol PO or IM every 4–8 h as needed, or olanzapine 2.5–10 mg IM repeated at 2 and 6 h, if needed).
InterventionThere are two main elements to intervention in a person with alcoholism:MOTIVATIONAL INTERVIEWINGFRAMES:Feedback to the patient;Responsibility to be taken by the patient;Advice, rather than orders, on what needs to be done; Menus of options that might be considered; Empathy for understanding of the patients thoughts and feelings; Self-efficacy, i.e., offering support for the capacity of the patient to succeed in makingchanges.Brief interventions•Discussions focus on consequences of high alcohol consumption, suggestedapproaches to stopping drinking, and help in recognizing and avoiding situations likely tolead to heavy drinking.
Alcohol Withdrawal Tremor of the hands (shakes) Agitation and anxiety Increase in pulse, respiratory rate, and body temperature Insomnia.• These symptoms usually begin within 5–10 h of decreasing ethanol intake, peak on day 2 or 3, and improve by day 4 or 5, although mild levels of these problems may persist for 4–6 months as a protracted abstinence syndrome.
• seizure (2–5%)• delirium tremens (DTs), where the withdrawal includes delirium (mental confusion, agitation, and fluctuating levels of consciousness)
Treating withdrawal 50–100 mg ofsearch for evidence of liver failure, thiamine daily gastrointestinal bleeding, cardiac arrhythmia, infection 25–50 mg of chlordiazepoxide or glucose 10 mg of diazepam given PO electrolytes every 4–6 h on the first day, with doses then decreased to zero over the next 5 days
Treatment of the patient with DTs- Identify and correct medical problems and to control behavior and prevent injuries. High doses of a benzodiazepine (as much as 800 mg/d of chlordiazepoxide), Antipsychotic medications, such as haloperidol or olanzapine Generalized withdrawal seizures rarely require more than giving an adequate dose of benzodiazepines.• Phenytoin• gabapentin• status epilepticus
Rehabilitationof Alcoholics Cognitive-behavioral approaches Counseling Vocational rehabilitation Self-help groups such as alcoholics anonymous Relapse prevention.
Physician’s role Identifying the alcoholic Diagnosing and treating associated medical or psychiatric syndromes Overseeing detoxification Referring the patient to rehabilitation programs, Providing counseling Medication as needed
Medications for RehabilitationDrug Dosage MOA BENIFIT REMarksNALTREXONE 50–150 MG/D BLOCKING OPIOID SHORTEN G ALLELE OF ORALLY, RECEPTORS, DECREASE SUBSEQUENT THE AII8G ACTIVITY IN THE DOPAMINE- RELAPSES POLYMORPHISM RICH VENTRAL TEGMENTAL REWARD SYSTEMACAMPROSAT 2 G/D DIVIDED INHIBITS NMDA RECEPTORS DECREASINGE INTO THREE MILD ORAL DOSES SYMPTOMS OF PROTRACTED WITHDRAWAL.DISULFIRAM, 250 MG/D. PRODUCES VOMITING AND AVERSION CAN BE AUTONOMIC NERVOUS THERAPY DANGEROUS SYSTEM INSTABILITY IN THE WITH HEART PRESENCE OF ALCOHOL AS DISEASE, A RESULT OF RAPIDLY STROKE, RISING BLOOD LEVELS OF DIABETES THE FIRST METABOLITE OF MELLITUS, OR ALCOHOL, ACETALDEHYDE HYPERTENSION
Refrences• Dan Longo, Anthony Fauci, Dennis Kasper et al Harrisons Principles of Internal Medicine 18th Ed. 2011• Bickram Pradhan et al, The alcohol use disorders identification test(AUDIT): validation of a Nepali version for the detection of alcohol use disorders and hazardous drinking in medical settings.• Kumar S et. Al, Alcohol use among physicians ina medical school in Nepal; Kathmandu University Medical Journal (2006), Vol. 4, No. 4, Issue 16, 460-464
• World Health Organization (2008c). Global Survey on Alcohol and Health. Geneva (http://www.who.int/substance_abuse/activities/gad/en/, accessed 28 November 2010)• Peter D. Friedmann, Alcohol Use in Adults, clinical pr actice; N Engl J Med 2013;368:365-73.
Thank you•“Alcohol may be mans worst enemy, but the Bible says love your enemy.”
• “Alcohol may be mans worst enemy, but the Bible says love your enemy.”
• "I dont care how liberated this world becomes, a man will always be judged by the amount of alcohol he can consume, and a woman will be impressed, whether she likes it or not. “• -Doug Coughlin from Cocktail