Alcohol Use DisordersPresented by: Ashish K. Tripathi Roll no: 651 Resource Faculty: Prof. P. M. Shyangwa
contents: What is alcohol? Mechanism of Action, Metabolism Terminologies Magnitude of Problem (Epidemiology) Acute intoxication and Withdrawal Syndromes (Uncomplicated and Complicated) General Principles of Management of Alcohol Dependence
What is Alcohol Alcohol Dehydrogenase Aldehyde Dehydrogenase
Mechanism of Action of Alcohol Produce CNS depression by a generalized membrane action by altering the state of membrane lipids. Promotes GABAA Receptor mediated synaptic inhibition through Chloride channel opening as well as inhibits NMDA and kainate types of excitatory amino acid receptors. Indirectly reduce neurotransmitter release by inhibiting voltage sensitive neuronal Calcium Channels Turnover of NA in brain is enhanced by alcohol through an opioid receptor dependent mechanism: probably important in pleasurable effects and alcohol dependence
Terminologies Excess consumption of Alcohol: Daily or weekly intake of alcohol exceeding the specified amount(upto 21 units/week for men and 14 units/week for women). Also known as hazardous drinking. u Alcohol Misuse: Drinking that causes mental, physical and social harm to an individual. Doesn’t include those with formal alcohol dependence. h Alcohol Dependence: Used when criteria for dependence is met (Next slide) t Problem Drinking: Those in whom drinking has caused an alcohol related disorder or disability Alcoholism: If used, should be regarded as a short hand way of referring to some condition of these 4 conditions
Criteria for Alcohol Dependence in ICD 10 A diagnosis of Dependence should be made if ≥ 3 of following have been experienced or exhibited in the last year 1. A strong desire or sense of compulsion to take alcohol 2. Difficulty in controlling alcohol taking behavior 3. Physiological withdrawal state when alcohol use has been ceased or reduced 4. Evidence of tolerance: Increased doses required 5. Progressive neglect of Alternative pleasures or interests because of alcohol use 6. Persisting with alcohol use despite clear evidence of harmful consequences (physical and mental)
Magnitude of Problem At some time during life- 90% of population in US drink with most people beginning in early to middle teens. By end of high school- 80% of students have consumed alcohol and more than 60% have been intoxicated. About 30-40% persons with alcohol related disorder meet the diagnostic criteria for Major Depressive Disorder sometime during their lifetime. About 2,00,000 deaths each year are directly related to alcohol use. Drunken drivers are involved in about 50% of all automobile fatalities. Alcohol use and alcohol related disorders are also associated with about 50% of all homicides and 25% of all suicides.
Magnitude of the Problem The prevalence of alcohol dependence in Dharan was found to be 25.8%. The prevalence of alcohol dependence increased with age to peak in the age group 45-54 years and was more than twice as common in men as in women.(British journal of addiction , Shyangwa et al) The net effect of alcohol consumption on health is detrimental, with an estimated 3.8% of all global deaths and 4.6% of global disability-adjusted life-years attributable to alcohol.(Lancet. 2009 Jun 27)
Complications 1. Medical Complications A CNS Peripheral Neuropathy Delirium tremens Rum fits Alcohol Hallucinosis Wernicke- Korsakoff psychosis Alcohol Dementia B. . GIT Fatty liver, cirrhosis, hepatitis, HCC, Liver failure Gastritis, GERD, peptic ulcer, Ca stomach and esophagus Pancreatitis Others Malnutition, pellagra Cardiomyopathy Sexual Dysfunction Fetal alcohol syndrome
Social Complications Accidents Marital disharmony Divorce Occupational problems Increased incidence of drug dependence Criminality and Financial difficulties
Acute intoxication 1. Slowed thinking 2. Increase reaction time 3. Slurred Speech 4. Incoordination 5. Unsteady Gait 6. Nystagmus 7. Impairment of Memory 8. ComaBlood Concentration of 80-100 milligram of Ethanol per decilitre of Blood which is the same as 0.8-.10 gm per decilitre - US
Impairments likely to be seen in differentBlood Alcohol ConcentrationsLevel Likely Impairment20-30 mg/dl Slowed motor performance and decreased thinking ability30-80 mg/dl Increase in motor and Cognitive problems80-200 mg/dl Increase in incoordination and judgment errors, mood liability200-300 mg/dl Nystagmus, marked slurrring of speech, and alcoholic> 300 mg/dl blackoutsvital signs and possible death ImpairedTreatment:Chlordiazepoxide oral 25-100 mg every 4-6 hrs.Initial dose can be repeated every 2 hours until patient iscalm.Subsequent doses must be individualized and titrated.
Withdrawal syndrome Symptoms range from mild anxiety and sleep disturbance to life threatening state known as delirium tremens Generally occur in people who have been drinking heavily for years and who maintain a high intake of alcohol for weeks at a time. Symptoms follow a drop in blood concentration. Characteristically appear on waking after the fall in concentration during sleep Earliest and commonest: Acute tremulousness of hands, legs and trunk Symptoms and Signs of Acute Alcohol Withdrawal Anxiety, agitation and insomnia Tachycardia and sweating Tremors of limbs, trunk and eyelids Nausea and Vomiting Seizures, Confusion and Hallucinations
Treatment Detoxification: The drug of choice is benzodiazepines: chlordiazipoxide(80-200mg in divided doses) and diazepam 40-80 mg in divided doses or lorazepam 8-16 mg in divided doses.
Moderate alcohol dependence: Chlordiazepoxide 20mg QID → day 1 15mgQID → day2 10mg QID → day3 5mgQID →day4 5mgBD →day5 In more severe dependence higher doses are needed for longer periods.
In addition vitamin should be administered: Multivitamins containing 100 mg of thiamine should be administered pareterally twice daily for 3-5 days followed by oral administration of vitamin B1 for 6 months. Care of hydration should be taken.
Complicated Withdrawal syndrome may be characterized by following disturbances:1.Delirium Tremens: Occurs within 2 to 4 days of significant abstinence from heavy alcohol drinking with characteristic features of:- Clouding of consciousness with disorientation in time and place Poor attention span and distractibility Visual hallucinations and illusions Marked autonomic disturbances Insomnia Dehydration with electrolyte imbalance Prevention: 25-50 mg of Chlordiazepoxide every 2-4 hrs until out of danger. Treatment: 50-100 mg Chlordiazepoxide every 4 hrs orally or Lorazepam IV 0.1 mg/kg at 2 mg/min. High calorie, high carbohydrate diet given with Thiamine.
2. Alcoholic Seizure (Rum Fits) Generalized tonic clonic seizures occur in about 10% of alcohol dependence patients, usually 12 to 48 hrs after abstinence. Multiple seizures are more common Sometimes status epileptics can be precipitated (less than 3%) Treatment: BDZ: Diazepam: IV 0.5 mg/kg at 2.5 mg/ min3. Alcoholic hallucinosis: Occurs in about 2% of patients Characterized by presence of hallucinations [usually auditory] during partial or complete abstinence, following regular alcohol intake. Treatment: Lorazepam oral 3-10 mg every 4-6 hr
Neuropsychiatric complications of chronicalcohol use: Wernicke-Korsakoff Syndrome Include Wernicke’s Encephalopathy (acute symptoms) and Korsakoff’s Syndrome (Chronic Condition) Werkinck’s encephalopathy is completely reversible with treatment whereas only about 20% of patients with Korsakoff’s Syndrome Recover. Thiamine deficiency leads to both. Thiamine: A co-factor for several important enzymes, involved in synaptic transmission, conduction of axon potential along axon.
Wernicke’s Encephalopathy Acute reaction to a severe deficiency of thiamine, secondary to alcohol abuse. Ataxia, vestibular dysfunction, confusion, ocular motility abnormalities (lateral rectal palsy, horizontal nystagmus, gaze palsy) Treatment: Large doses of parenteral Thiamine which prevents progression into Korsakoff’s syndrome 100 mg oral 8-12 hrly for 1-2 weeks.
Korsakoff’s Syndrome Chronic condition, follows Wernicke’s encephalopathy. Organic amnestic syndrome (esp. recent memory) Amnesia in an alert & responsive patient. Usually associated with confabulation. Treatment: Thiamine 100 mg oral 8-12 hrly for 3-12 months.
Other Complications: Marchiafava-Bignami disease Alcoholic dementia Cerebellar degeneration Peripheral neuropathy Central pontine myelinosis
General Principles of Management of Alcohol DependenceImportant steps before treatment Ruling out any physical disorder Ruling out any psychiatric disorder Assessment of motivation for treatment Assessment of social support system Assessment of personality characteristics of patients Assessment of current and past social, interpersonal and occupational functioning
Treatment of alcohol dependenceA. Behavior therapy:aversion therapy using sub threshold electric shock or an emetic like apomorphine.B. Psychotherapy: Pt should be educated about the risk of continuing alcohol about and asked to resume personal responsibility for change and be given a choice of options for change.C. Group therapyD. Deterrent agents: (Alcohol sensitizing Drugs) disulfiram 250-500mg/day in first week and 250 mg/day for maintenance. others : citrated calcium carbimide, metronidazole,nitrafezole
E. Anti-craving agents: Acamprosate, naltrexone, and SSRIs[eg-fluoxetine]F. Other medications : Antidepressants, antipsychotic, lithium, carbamazepine. Psychosocial rehabilitation
References Kaplan & Sadock’s Synopsis of psychiatry (10th edition) Shorter Oxford textbook of psychiatry (5thedition)A short textbook of psychiatry (6thedition) - Niraj Ahuja British journal of addiction Lancet. 2009 Jun 27; (Rehm J, Mathers C, Popova S, Thavorncharoensap M, Teerawattananon Y, Patra J.Centre for Addiction and Mental Health, Toronto)