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ALCOHOL MISUSE AND DEPENDENCE  Dr. Mohammad Shaikhani
The problem:   <ul><li>Alcohol consumption associated with social, psychological & physical problems constitutes harmful u...
Categories and Definitions for Patterns of Alcohol Use The CAGE Questionnaire Mod drink  NIAAA  Men,≤2 drinks / day   Wome...
Categories and Definitions for Patterns of Alcohol Use The CAGE Questionnaire At-risk drinking  NIAAA  Men, >14 drinks/wee...
Categories and Definitions for Patterns of Alcohol Use The CAGE Questionnaire Hazardous drinking  WHO  At risk for adverse...
Categories and Definitions for Patterns of Alcohol Use The CAGE Questionnaire Alcohol abuse (DSM-IV)  APA  1 or more  of t...
Categories and Definitions for Patterns of Alcohol Use The CAGE Questionnaire Alcohol dependance (DSM-IV)  APA  3 or more ...
The problem:Diagnosis   <ul><li>There are several screening instruments:  </li></ul><ul><li>A single question, “How many t...
The problem:lab diagnosis   <ul><li>Lab findings such as an elevated MCV (sensitivity 63%; specificity 48%) & elevated asp...
The problem: Management   <ul><li>Referral for specialty treatment.  </li></ul><ul><li>For alcohol misuse, brief behaviora...
The problem:Management   <ul><li>3 oral medications are currently approved for treating alcohol dependence, but they are m...
The problem:Management   <ul><li>Disulfiram causes a reaction of flushing, sweating, nausea, and tachycardia when the pati...
The problem:Management   <ul><li>Naltrexone reduces alcohol cravings & causes a lesser reward in response to drinking. It ...
The problem:Management   <ul><li>Acamprosate’s alcohol-related action is unclear, but it may reduce abstinence-related sym...
The CAGE Questionnaire   The CAGE Questionnaire <ul><li>Have you ever felt you should CUT down on your drinking?  </li></u...
CRITERIA FOR ALCOHOL DEPENDENCE   : The CAGE Questionnaire <ul><li>Narrowing of drinking repertoire (restriction to 1 type...
Aetiology: The CAGE Questionnaire <ul><li>Availability of alcohol & social patterns of use appear to be the most important...
Diagnosis: The CAGE Questionnaire <ul><li>Alcohol misuse may emerge during the patient's history, although patients may mi...
Complications: The CAGE Questionnaire <ul><li>These are protean and virtually any organ can be involved </li></ul><ul><li>...
Psychosocial problems: The CAGE Questionnaire <ul><li>Depression is common, usually reactive to the numerous social proble...
Brain effects: The CAGE Questionnaire <ul><li>The familiar features of drunkenness are ataxia, slurred speech, emotional i...
CONSEQUENCES OF CHRONIC ALCOHOL MISUSE   : The CAGE Questionnaire Acute intoxication Emotional & behavioural disturbance  ...
MEDICAL CONSEQUENCES   : The CAGE Questionnaire Neurological Peripheral neuropathy  Cerebellar degeneration  Cerebral haem...
MEDICAL CONSEQUENCES   : The CAGE Questionnaire Skin Spider naevi ,Palmar erythema  Duypuytren's contractures ,Telangiecta...
PSYCHIATRIC &CEREBRAL CONSEQUENCES   : The CAGE Questionnaire Depression  Alcoholic hallucinosis  Alcoholic 'blackouts'  W...
PSYCHIATRIC AND CEREBRAL CONSEQUENCES   : Wernicke-Korsakoff syndrome. The CAGE Questionnaire <ul><li>A rare but important...
Management   : The CAGE Questionnaire <ul><li>Advice about the harmful effects of alcohol & safe levels of consumption is ...
Management   : The CAGE Questionnaire <ul><li>Prevention of the Wernicke-Korsakoff complex requires the immediate use of h...
Unhealthy Alcohol Use Is a  Significant Public Health Problem  <ul><li>85,000 alcohol-related deaths </li></ul><ul><li>Sub...
What is the Difference Between Risky Alcohol Use and Alcohol Abuse? 7+ drinks/week 3 drinks/occasion Risky Alcohol Use 14+...
What Determines Alcohol Dependency? 1.  Tolerance 2.  Withdrawal 3.  Significant time spent obtaining/using  alcohol, or r...
Moderate Alcohol Use Has Some Health Benefits, But It Affects People Differently Possible Benefits Possible Harmful Effect...
How Does A Person Know If His/Her Alcohol Use is Unhealthy? <ul><li>Have you felt you should cut down? </li></ul><ul><li>H...
The AUDIT Test Includes 10 Questions with Multiple Choice Answers Scaled 0 to 4 How often do you have a drink containing a...
Nine Steps to Help Prevent Long-Term Disability from Unhealthy Alcohol Use 1.  Gather information 2.  Express concern 3.  ...
 
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Alcohol for 5th.

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Alcohol for 5th.

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  • (Title Appears) Unhealthy alcohol use is a significant public health problem in the United States and around the world. (Blue Text Box Appears) Annually in the United States, there are (1 st Bullet Appears) 85,000 alcohol-related deaths, as well as (2 nd Bullet Appears) substantial disability from the medical, psychological and trauma-related effects of alcohol use. 1,2,3 Despite this, drinking alcohol is somewhat common in our culture, and unhealthy use often gets ignored or goes undetected. (Text Box Appears) The spectrum of alcohol behaviors in our country extends from abstinence to dependency. ( Pyramid &amp; Bottom Text Appears) Approximately 30 percent of Americans are abstinent, (Line &amp; 2 nd From Bottom Text Appears) 30 percent are low-risk alcohol users, (Line &amp; 2 nd From Top Text Appears) 30 percent are risky with their alcohol use, and (Line, Arrow &amp; Top Text Appears) 10 percent are abusive or dependent. 1
  • (Title &amp; 1 st Blue Text Box Appear) Risky use is defined as (1 st &amp; 2 nd Text Lines Appear) more than 7 drinks per week, or 3 per occasion, in women, and (Line, 3 rd &amp; 4 th Text Lines Appear) more than 14 drinks per week, or four per occasion, in men, with (5 th Text Line Appears) no alcohol related consequences – at least not yet. 1 According to a study in the New England Journal of Medicine, those suffering from (2 nd Blue Text Box Appears) alcohol abuse have experienced (6 th Text Line Appears) recurrences of the following situations in the last 12 months: (1 st LH Bullet Appears) failure to fulfill major role obligations, (2 nd LH Bullet Appears) alcohol use in hazardous situations, (1 st RH Bullet Appears) alcohol-related legal problems, or (2 nd RH Bullet Appears) social or interpersonal problems resultant from alcohol.
  • (Title &amp; Blue Text Box Appears) Those with alcohol dependency suffer “clinically significant impairment or distress in the presence of three or more of the following: (Bullet #1 &amp; Picture Appear) tolerance; (Bullet #2 Appears) withdrawal; (Bullet #3 Appears) a great deal of time spent obtaining alcohol, using alcohol, or recovering from its effects; (Bullet #4 Appears) reducing or giving up important activities because of alcohol; (Bullet #5 Appears) drinking more or longer than intended; (Bullet #6 Appears) a persistent desire or unsuccessful efforts to cut down or control use; (Bullet #7 Appears) continued use despite having a physical or psychological problem caused or exacerbated by alcohol.” 1
  • (Title Appears) While moderate use of alcohol may have (1 st LH Text Box Appears) mild health benefits -- namely, (2 nd LH Text Line Appears) some protection from ischemic heart disease and (3 rd LH Text Line Appears) stroke -- the effects of moderate use impact people differently based on (1 st LH Text Line Appears) their age, sex, genetics, and other factors. The benefit of a reduced risk of heart disease and stroke is often counterbalanced by the wide range of (1 st RH Text Box Appears) harmful effects, (1 st RH Text Line Appears) including liver disease, (2 nd RH Text Line Appears) pancreatitis, (3 rd RH Text Line Appears) motor vehicle accidents, (4 th RH Text Line Appears) gun-related trauma, (5 th RH Text Line Appears) hypertension, (6 th RH Text Line Appears) hemorrhagic stroke, and (7 th RH Text Line Appears) cancer of the esophagus, larynx and mouth. (Blue Text Box, LH Text Box, &amp; 1 st LH Text Line Appear) For men under age 34 and (2 nd LH Text Line Appears) women under age 45, those who do not drink alcohol at all have the lowest death rates. (RH Text Box &amp; 1 st RH Text Line Appear) For men 35 or older, those who have five or fewer drinks a week have the lowest death rates. (2 nd RH Text Line Appears) For women over 45, those who take two or fewer drinks per week live the longest. 1
  • (Title Appears) How does one know if their alcohol use is unhealthy? Two tests in particular are useful for self-evaluation and clinical screening – they’re known as CAGE and AUDIT. 4 ( Blue Text Box Appears) CAGE asks four questions: (Bullet #1 Appears) Have you ever felt you should cut down on your drinking? (Bullet #2 Appears) Have people annoyed you by criticizing your drinking? (Bullet #3 Appears) Have you ever felt bad or guilty about your drinking? (Bullet #4 Appears) Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover? (Bottom blue text box and Text Line Appear) One or two affirmative answers indicates a high likelihood of unhealthy alcohol use.
  • (Title Appears) The AUDIT test includes 10 questions with multiple choice answers scaled 0 to 4. For example, the first question – (1 st blue text box and 1 st text line Appears) “How often do you have a drink containing alcohol?” -- provides the following answers and scores: never (0), monthly or less (1), 2 to 4 times a month (2), 2 to 3 times a week (3), 4 or more times a week (4). Some of the other questions are: (2 nd Text Line Appears) How many drinks of alcohol do you have on a typical day when you are drinking? (3rd Text Line Appears) How often do you have six or more drinks on one occasion? (4 th Text Line Appears) How often during the past year have you found you were not able to stop drinking once you had started? (5th Text Line Appears) How often during the past year have you failed to do what was normally expected from you because of drinking? (6th Text Line Appears) Has a relative, friend, doctor or other health worker been concerned about your drinking or suggested you cut down? (2 nd Blue Text Box Appears and bottom line of text appear) After answering all 10 questions, a score of 8 or more is associated with a high likelihood of unhealthy alcohol use. 1
  • (Title, Text Box Outline &amp; 1 st Bold Text Line Appears) Prevention of long-term disability from unhealthy alcohol use in a patient or loved one requires (LH Bullet Appears) intervention, (Middle Bullet Appears) tailored treatment plans, and (RH Bullet Appears) supportive follow-up. To get involved and address a suspected problem, here are nine steps to follow: (Bullet #1 Appears) 1) Gather information. Ask -- “What do you think about your drinking?” (Bullet #2 Appears) 2) Express concern. (Bullet #3 Appears) 3) Provide specific feedback, like, “Alcohol use is very common, but fewer than 1 in 10 people your age drink the amount you’re drinking.” (Bullet #4 Appears) 4) Express empathy -- “Quitting is difficult, but you are a strong person.” (Bullet #5 Appears) 5) Offer help -- “Would you like more information on how to cut down?” (Bullet #6 Appears) 6) Know local referral options -- “There are many resources. Here are two contacts that can help.” (Bullet #7 Appears) 7) Reinforce self-worth -- “Please think about your drinking because there are many people who care deeply about you.” (Bullet #8 Appears) 8) Assist with a plan -- “Let me help you make an appointment with an expert.” (Bullet #9 Appears) 9) Follow-up -- “Let’s schedule time to get together on a regular basis to monitor your success.” 7.8   The most unhealthy thing about unhealthy alcohol use is that we allow it to remain largely undetected and unaddressed.  
  • (Title, Text Box Outline &amp; 1 st Bold Text Line Appears) Prevention of long-term disability from unhealthy alcohol use in a patient or loved one requires (LH Bullet Appears) intervention, (Middle Bullet Appears) tailored treatment plans, and (RH Bullet Appears) supportive follow-up. To get involved and address a suspected problem, here are nine steps to follow: (Bullet #1 Appears) 1) Gather information. Ask -- “What do you think about your drinking?” (Bullet #2 Appears) 2) Express concern. (Bullet #3 Appears) 3) Provide specific feedback, like, “Alcohol use is very common, but fewer than 1 in 10 people your age drink the amount you’re drinking.” (Bullet #4 Appears) 4) Express empathy -- “Quitting is difficult, but you are a strong person.” (Bullet #5 Appears) 5) Offer help -- “Would you like more information on how to cut down?” (Bullet #6 Appears) 6) Know local referral options -- “There are many resources. Here are two contacts that can help.” (Bullet #7 Appears) 7) Reinforce self-worth -- “Please think about your drinking because there are many people who care deeply about you.” (Bullet #8 Appears) 8) Assist with a plan -- “Let me help you make an appointment with an expert.” (Bullet #9 Appears) 9) Follow-up -- “Let’s schedule time to get together on a regular basis to monitor your success.” 7.8   The most unhealthy thing about unhealthy alcohol use is that we allow it to remain largely undetected and unaddressed.  
  • Transcript of "Alcohol for 5th."

    1. 1. ALCOHOL MISUSE AND DEPENDENCE Dr. Mohammad Shaikhani
    2. 2. The problem: <ul><li>Alcohol consumption associated with social, psychological & physical problems constitutes harmful use . </li></ul><ul><li>1/4 of male patients in general hospital medical wards in the UK have a current or previous alcohol problem </li></ul><ul><li>Alcohol misuse definitions include: </li></ul><ul><li>“ Risky/hazardous” </li></ul><ul><li>“ Harmful” drinking. </li></ul><ul><li>Risky drinkers consume alcohol above levels considered moderate. </li></ul><ul><li>Harmful drinkers experience current harm associated with alcohol use but do not meet criteria for dependence. </li></ul><ul><li>The USPSTF recommends routine screening to identify persons whose alcohol use puts them at risk. </li></ul><ul><li>Although the optimal interval for screening is not known, persons more likely to be at risk are those with prior alcohol problems, young adults, smokers. </li></ul><ul><li>More frequent screening may be beneficial in these populations. </li></ul>The CAGE Questionnaire
    3. 3. Categories and Definitions for Patterns of Alcohol Use The CAGE Questionnaire Mod drink NIAAA Men,≤2 drinks / day Women, ≤1 drink/day >65 ys, ≤1 drink/day Category Organization Definition
    4. 4. Categories and Definitions for Patterns of Alcohol Use The CAGE Questionnaire At-risk drinking NIAAA Men, >14 drinks/week or >4 drinks/ occasion Women, >7 drinks/week or >3 drinks/occasion Category Organization Definition
    5. 5. Categories and Definitions for Patterns of Alcohol Use The CAGE Questionnaire Hazardous drinking WHO At risk for adverse consequences from alcohol Harmful drinking WHO Alcohol causing physical or psychological harm Category Organization Definition
    6. 6. Categories and Definitions for Patterns of Alcohol Use The CAGE Questionnaire Alcohol abuse (DSM-IV) APA 1 or more of the following events in a 12-month period: • Recurrent use resulting in failure to fulfill major role obligations • Recurrent use in hazardous situations • Recurrent alcohol-related legal problems • Continued use despite social or interpersonal problems caused or exacerbated by alcohol use Category Organization Definition
    7. 7. Categories and Definitions for Patterns of Alcohol Use The CAGE Questionnaire Alcohol dependance (DSM-IV) APA 3 or more of the following events in a 12-month period: • Tolerance (increased amounts to achieve effect or diminished effect from same amount) • Withdrawal • Great deal of time spent obtaining alcohol, using it, or recovering from its effects • Important activities given up or reduced because of alcohol • Drinking more or longer than intended • Persistent desire or unsuccessful efforts to cut down or control alcohol use • Use continued despite knowledge of having a psychological problem caused or exacerbated by alcohol Category Organization Definition
    8. 8. The problem:Diagnosis <ul><li>There are several screening instruments: </li></ul><ul><li>A single question, “How many times in the past have you had five or more drinks (for men) or four or more drinks (for women) in a day?” can be used to screen for at-risk drinkers. </li></ul><ul><li>The CAGE questionnaire is a commonly used instrument to identify alcohol problems: </li></ul><ul><li>C Have you ever felt you should cut down on your drinking? </li></ul><ul><li>A Have people annoyed you by criticizing your drinking? </li></ul><ul><li>G Have you ever felt bad or guilty about your drinking? </li></ul><ul><li>E Eye opener: Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover? </li></ul><ul><li>With a cutoff of two positive answers, the CAGE questionnaire is 77-94% sensitive& 79- 97% specific for detecting alcohol abuse or dependence in primary care settings& indicates that further assessment is warranted; the test may be less accurate in women & blacks. Other screening instruments are available at www.niaaa.nih.gov/Publications/AlcoholResearch / . </li></ul>The CAGE Questionnaire
    9. 9. The problem:lab diagnosis <ul><li>Lab findings such as an elevated MCV (sensitivity 63%; specificity 48%) & elevated aspartate aminotransferase/alanine aminotransferase ratio (sensitivity 12%; specificity 91%) can be suggestive but are not diagnostic of alcohol abuse & dependence. </li></ul>The CAGE Questionnaire
    10. 10. The problem: Management <ul><li>Referral for specialty treatment. </li></ul><ul><li>For alcohol misuse, brief behavioral counseling (such as the five A’s & the five R’s used for smoking quiting) may be useful. </li></ul><ul><li>Adjunctive drug therapy may be considered for patients who previously failed to benefit from psychosocial approaches alone &those who have recently stopped drinking but are experiencing cravings or relapses. </li></ul>The CAGE Questionnaire
    11. 11. The problem:Management <ul><li>3 oral medications are currently approved for treating alcohol dependence, but they are most effective when combined with some behavioral support. </li></ul>The CAGE Questionnaire
    12. 12. The problem:Management <ul><li>Disulfiram causes a reaction of flushing, sweating, nausea, and tachycardia when the patient ingests alcohol. It is most effective when medication compliance can be monitored. Contraindications are use of alcohol-containing preparations, metronidazole, severe cardiac disease& unwillingness to completely abstain from alcohol. </li></ul>The CAGE Questionnaire
    13. 13. The problem:Management <ul><li>Naltrexone reduces alcohol cravings & causes a lesser reward in response to drinking. It is contraindicated if a patient is dependent on or taking opioids or has liver disease. </li></ul>The CAGE Questionnaire
    14. 14. The problem:Management <ul><li>Acamprosate’s alcohol-related action is unclear, but it may reduce abstinence-related symptoms, such as anxiety, restlessness, and dysphoria. It is contraindicated in severe renal disease. </li></ul><ul><li>There is no proven benefit for combining these medications. </li></ul><ul><li>A reasonable minimum duration of adjunctive drug therapy is 3 months, with treatment continuing a year or longer if the patient responds. </li></ul>The CAGE Questionnaire
    15. 15. The CAGE Questionnaire The CAGE Questionnaire <ul><li>Have you ever felt you should CUT down on your drinking? </li></ul><ul><li>Have people ANNOYED you by criticizing your drinking? </li></ul><ul><li>Have you ever felt bad or GUILTY about your drinking? </li></ul><ul><li>Do you ever have a drink first thing in the morning to steady you or help a hangover? (an EYE opener) </li></ul>
    16. 16. CRITERIA FOR ALCOHOL DEPENDENCE : The CAGE Questionnaire <ul><li>Narrowing of drinking repertoire (restriction to 1 type of alcohol as spirits) </li></ul><ul><li>Priority of drinking over other activities (salience) </li></ul><ul><li>Tolerance of effects of alcohol </li></ul><ul><li>Repeated withdrawal symptoms </li></ul><ul><li>Relief of withdrawal symptoms by further drinking </li></ul><ul><li>Subjective compulsion to drink </li></ul><ul><li>Reinstatement of drinking behaviour after abstinence </li></ul>
    17. 17. Aetiology: The CAGE Questionnaire <ul><li>Availability of alcohol & social patterns of use appear to be the most important factors. </li></ul><ul><li>Genetic factors may play some part in predisposition to dependence. </li></ul><ul><li>The majority of alcoholics do not have an associated psychiatric illness, but a few drink heavily in an attempt to relieve anxiety or depression. </li></ul>
    18. 18. Diagnosis: The CAGE Questionnaire <ul><li>Alcohol misuse may emerge during the patient's history, although patients may minimise their intake. </li></ul><ul><li>It may also present via its effects on one or more aspects of the patient's life. </li></ul><ul><li>Alcohol dependence commonly presents with withdrawal in those admitted to hospital, as they can no longer maintain their high alcohol intake. </li></ul>
    19. 19. Complications: The CAGE Questionnaire <ul><li>These are protean and virtually any organ can be involved </li></ul><ul><li>Alcohol has replaced syphilis as the great mimic of disease. </li></ul><ul><li>Social problems include absenteeism from work, unemployment, marital tensions, child abuse, financial difficulties & problems with the law, such as violence/ traffic offences. </li></ul>
    20. 20. Psychosocial problems: The CAGE Questionnaire <ul><li>Depression is common, usually reactive to the numerous social problems which heavy drinking creates. </li></ul><ul><li>Alcohol also has a direct depressant effect. </li></ul><ul><li>Attempted suicide & completed suicide are often associated with alcohol misuse. </li></ul><ul><li>Anxiety is relieved by alcohol. </li></ul><ul><li>People who are socially anxious may consequently use alcohol in this way & may develop dependence& Conversely, alcohol withdrawal increases anxiety. </li></ul><ul><li>Alcoholic hallucinosis is a rare condition in which alcoholic individuals experience auditory hallucination in clear consciousness. </li></ul><ul><li>Alcohol withdrawal: Symptoms usually become maximal about 2 days after the last drink& can include seizures ('rum fits'). </li></ul><ul><li>Delirium tremens is a form of delirium associated with severe alcohol withdrawal with significant mortality& morbidity </li></ul>
    21. 21. Brain effects: The CAGE Questionnaire <ul><li>The familiar features of drunkenness are ataxia, slurred speech, emotional incontinence & aggression. </li></ul><ul><li>Very heavy drinkers may experience periods of amnesia for events which occurred during bouts of intoxication, termed 'alcoholic blackouts'. </li></ul><ul><li>Established alcoholism may lead to alcoholic dementia, a global cognitive impairment resembling Alzheimer's disease, but which does not progress if the patient becomes abstinent. </li></ul><ul><li>Indirect effects on behaviour can result from head injury, hypoglycaemia &portosystemic encephalopathy </li></ul>
    22. 22. CONSEQUENCES OF CHRONIC ALCOHOL MISUSE : The CAGE Questionnaire Acute intoxication Emotional & behavioural disturbance Medical problems: hypoglycaemia, aspiration of vomit, respiratory depression Complicating other medical problems Accidents&injuries sustained in fights Withdrawal phenomena Psychological symptoms: restlessness, anxiety, panic attacks Autonomic symptoms: tachycardia, sweating, pupil dilation, nausea, vomiting Delirium tremens: agitation, hallucinations, illusions, delusions Seizures
    23. 23. MEDICAL CONSEQUENCES : The CAGE Questionnaire Neurological Peripheral neuropathy Cerebellar degeneration Cerebral haemorrhage Dementia Hepatic Fatty change,hepatiti, & cirrhosis, Liver cancer Gastrointestinal Oesophagitis, gastritis Pancreatitis Oesophageal cancer Mallory-Weiss syndrome Malabsorption Oesophageal varices Respiratory Pulmonary TB ,Pneumonia
    24. 24. MEDICAL CONSEQUENCES : The CAGE Questionnaire Skin Spider naevi ,Palmar erythema Duypuytren's contractures ,Telangiectasiae Cardiac Cardiomyopathy Hypertension Musculoskeletal Myopathy Fractures Endocrine and metabolic Pseudo-Cushing's syndrome Hypoglycaemia ,Gout Reproductive Hypogonadism Fetal alcohol syndrome Infertility
    25. 25. PSYCHIATRIC &CEREBRAL CONSEQUENCES : The CAGE Questionnaire Depression Alcoholic hallucinosis Alcoholic 'blackouts' Wernicke's encephalopathy: nystagmus, opthalmoplegia, ataxia, confusion Korsakoff's syndrome: short-term memory deficits, confabulation
    26. 26. PSYCHIATRIC AND CEREBRAL CONSEQUENCES : Wernicke-Korsakoff syndrome. The CAGE Questionnaire <ul><li>A rare but important effect of chronic alcohol misuse </li></ul><ul><li>This organic brain disorder results from damage to the mamillary bodies, dorsomedial nuclei of the thalamus & adjacent areas of grey matter. </li></ul><ul><li>It is caused by a deficiency of thiamin (vitamin B1), which is most commonly caused by long-standing heavy drinking & an inadequate diet. </li></ul><ul><li>Without prompt treatment, the acute presentation of Wernicke's encephalopathy (nystagmus, ophthalmoplegia, ataxia & confusion) can progress to the irreversible deficits of Korsakoff's syndrome (severe short-term memory deficits & confabulation). </li></ul><ul><li>In those who die in the acute stage, microscopic examination of the brain shows hyperaemia, petechial haemorrhages& astrocytic proliferation. </li></ul>
    27. 27. Management : The CAGE Questionnaire <ul><li>Advice about the harmful effects of alcohol & safe levels of consumption is often all that is needed. </li></ul><ul><li>In more serious cases, patients may have to be advised to alter leisure activities or change jobs if these are contributing to the problem. </li></ul><ul><li>Supportive psychotherapy is often crucial in helping the patient make the necessary changes in lifestyle. </li></ul><ul><li>Psychological treatment is used for patients who have recurrent relapses &is usually available at specialised centres. </li></ul><ul><li>Support is also provided by voluntary organisations such as Alcoholics Anonymous (AA). </li></ul><ul><li>If alcohol dependence is suspected, withdrawal syndromes can be prevented, or treated once established, with benzodiazepines. </li></ul><ul><li>Large doses may be required (e.g. diazepam 20 mg 6-hourly), tailed off over a period of 5-7 days as symptoms subside. </li></ul>
    28. 28. Management : The CAGE Questionnaire <ul><li>Prevention of the Wernicke-Korsakoff complex requires the immediate use of high doses of thiamin, which may be given parenterally </li></ul><ul><li>There is no treatment for Korsakoff's syndrome once it has arisen. </li></ul><ul><li>The risk of side-effects, such as respiratory depression with benzodiazepines & anaphylaxis with B1, is small when weighed against the risks of no treatment. </li></ul><ul><li>Disulfiram (200-400 mg daily) can be given as a deterrent to patients who have difficulty resisting the impulse to drink after becoming abstinent. </li></ul><ul><li>It blocks the metabolism of alcohol, causing acetaldehyde to accumulate. When alcohol is consumed, an unpleasant reaction follows with headache, flushing and nausea. </li></ul><ul><li>Disulfiram always an adjunct to other treatments,esp psychotherapy. </li></ul><ul><li>Acamprosate (666 mg 8-hourly) maintain abstinence by reducing the craving for alcohol. </li></ul><ul><li>Only rarely are antidepressants required; depressive symptoms, if present, usually resolve with abstinence. </li></ul><ul><li>Antipsychotics as chlorpromazine required for alcoholic hallucinosis. </li></ul>
    29. 29. Unhealthy Alcohol Use Is a Significant Public Health Problem <ul><li>85,000 alcohol-related deaths </li></ul><ul><li>Substantial disability from consequences of alcohol use </li></ul>In the United States (per year) Abstinent - 30% Low-risk - 30% Abusive or dependent 10% Risky - 30% Alcohol Use Among Americans
    30. 30. What is the Difference Between Risky Alcohol Use and Alcohol Abuse? 7+ drinks/week 3 drinks/occasion Risky Alcohol Use 14+ drinks/week 4 drinks/occasion Women Men No Alcohol Related Consequences – YET! Alcohol Abuse Recurrences in the last 12 months of: <ul><li>Failure to fulfill major obligations </li></ul><ul><li>Alcohol use in hazardous situations </li></ul><ul><li>Related legal problems </li></ul><ul><li>Related social or interpersonal problems </li></ul>Source: Saitz R. Unhealthy Alcohol Use. NEJM. 2005;352:596-607.
    31. 31. What Determines Alcohol Dependency? 1. Tolerance 2. Withdrawal 3. Significant time spent obtaining/using alcohol, or recovering from its effects 4. Reducing or giving up important activities because of alcohol 5. Drinking more or longer than intended 6. Persistent desire or unsuccessful efforts to cut down or control use 7. Continued use despite problems caused or exacerbated by alcohol Those with alcohol dependency suffer clinically significant impairment or distress in the presence of three or more of the following: Source: Saitz R. Unhealthy Alcohol Use. NEJM. 2005;352:596-607.
    32. 32. Moderate Alcohol Use Has Some Health Benefits, But It Affects People Differently Possible Benefits Possible Harmful Effects <ul><li>(Varied based on age, sex, genetics) </li></ul><ul><li>Risk of ischemic heart disease </li></ul><ul><li>Risk of ischemic stroke </li></ul>Liver disease Pancreatitis Motor vehicle accidents Gun-related trauma Hypertension Hemorrhagic stroke Cancer Abstinence Low-Risk Use Men <34 Women <45 Men >35 Women >45 < 5 drinks/week < 2 drinks/week Lowest Mortality Rates Source: Saitz R. Unhealthy Alcohol Use. NEJM. 2005;352:596-607.
    33. 33. How Does A Person Know If His/Her Alcohol Use is Unhealthy? <ul><li>Have you felt you should cut down? </li></ul><ul><li>Have people annoyed you by criticizing your drinking? </li></ul><ul><li>Have you felt bad or guilty? </li></ul><ul><li>Do you drink first think in the morning? </li></ul>CAGE (4 questions) Unhealthy Use 1 or 2 Positives Sources: Saitz R. Unhealthy Alcohol Use. NEJM. 2005;352:596-607. Fiellin DA, Reid MC, O’Connor PG. Screening for alcohol problems in primary care: a systematic review. Arch Intern Med . 2000;160:1977-1989. Cited in Saitz R.
    34. 34. The AUDIT Test Includes 10 Questions with Multiple Choice Answers Scaled 0 to 4 How often do you have a drink containing alcohol? How many drinks do you have in one day? How often do you have six or more drinks? How often during the past year were you unable to stop drinking? How often during the past year have you failed to do what was normally expected from you? Has a relative, friend, doctor, or health care worker been concerned and suggested you cut down? Score of 8 or more AUDIT Unhealthy Use Sources: Saitz R. Unhealthy Alcohol Use. NEJM. 2005;352:596-607. Fiellin DA, Reid MC, O’Connor PG. Screening for alcohol problems in primary care: a systematic review. Arch Intern Med . 2000;160:1977-1989. Cited in Saitz R.
    35. 35. Nine Steps to Help Prevent Long-Term Disability from Unhealthy Alcohol Use 1. Gather information 2. Express concern 3. Provide feedback 4. Express empathy 5. Offer help Prevention requires: <ul><li>Intervention </li></ul><ul><li>Tailored treatment plans </li></ul><ul><li>Supportive follow-up </li></ul>6. Know local referral options 7. Reinforce self worth 8. Assist with a plan 9. Follow up Sources: Helping patients with alcohol problems: a health practitioner’s guide. Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism, January 2003. (NIH publication no. 03-3769.) Cited in Saitz R. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: recommendation statement. Ann Intern Med. 2004;140:554-556. Cited in Saitz R.
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