2. 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
4. 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
5. 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
6. 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)
7. 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.
8. 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)
9. 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
10. Social Complications
Accidents
Marital disharmony
Divorce
Occupational problems
Increased incidence of drug dependence
Criminality and
Financial difficulties
11. Acute intoxication
1. Slowed thinking
2. Increase reaction time
3. Slurred Speech
4. Incoordination
5. Unsteady Gait
6. Nystagmus
7. Impairment of Memory
8. Coma
Blood Concentration of 80-100 milligram of Ethanol per decilitre of
Blood which is the same as 0.8-.10 gm per decilitre - US
12. Impairments likely to be seen in different
Blood Alcohol Concentrations
Level Likely Impairment
20-30 mg/dl Slowed motor performance and decreased thinking ability
30-80 mg/dl Increase in motor and Cognitive problems
80-200 mg/dl Increase in incoordination and judgment errors, mood liability
200-300 mg/dl Nystagmus, marked slurrring of speech, and alcoholic
> 300 mg/dl blackoutsvital signs and possible death
Impaired
Treatment:
Chlordiazepoxide oral 25-100 mg every 4-6 hrs.
Initial dose can be repeated every 2 hours until patient is
calm.
Subsequent doses must be individualized and titrated.
13. 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
14. 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.
15. 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.
16. 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.
17. 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.
18. 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/ min
3. 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
19. Neuropsychiatric complications of chronic
alcohol 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.
20. 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.
21. 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.
23. General Principles of Management of
Alcohol Dependence
Important 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
24. Treatment of alcohol dependence
A. 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 therapy
D. Deterrent agents: (Alcohol sensitizing Drugs) disulfiram
250-500mg/day in first week and 250 mg/day for maintenance.
others :
citrated calcium carbimide, metronidazole,nitrafezole
25. E. Anti-craving agents: Acamprosate,
naltrexone, and SSRIs[eg-fluoxetine]
F. Other medications :
Antidepressants, antipsychotic, lithium,
carbamazepine.
Psychosocial rehabilitation
26. 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)
