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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 (1st Bullet Appears) 85,000 alcohol-related deaths, as well as (2nd 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 & Bottom Text Appears) Approximately 30 percent of Americans are abstinent, (Line & 2nd From Bottom Text Appears) 30 percent are low-risk alcohol users, (Line & 2nd From Top Text Appears) 30 percent are risky with their alcohol use, and (Line, Arrow & Top Text Appears) 10 percent are abusive or dependent.1
  • (Title & 1st Blue Text Box Appear) Risky use is defined as (1st & 2nd Text Lines Appear) more than 7 drinks per week, or 3 per occasion, in women, and (Line, 3rd & 4th Text Lines Appear) more than 14 drinks per week, or four per occasion, in men, with (5th 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 (2nd Blue Text Box Appears) alcohol abuse have experienced (6th Text Line Appears) recurrences of the following situations in the last 12 months: (1st LH Bullet Appears) failure to fulfill major role obligations, (2nd LH Bullet Appears) alcohol use in hazardous situations, (1st RH Bullet Appears) alcohol-related legal problems, or (2nd RH Bullet Appears) social or interpersonal problems resultant from alcohol.
  • (Title & 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 & 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 (1st LH Text Box Appears) mild health benefits -- namely, (2nd LH Text Line Appears) some protection from ischemic heart disease and (3rd LH Text Line Appears) stroke -- the effects of moderate use impact people differently based on (1st 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 (1st RH Text Box Appears) harmful effects, (1st RH Text Line Appears) including liver disease, (2nd RH Text Line Appears) pancreatitis, (3rd RH Text Line Appears) motor vehicle accidents, (4th RH Text Line Appears) gun-related trauma, (5th RH Text Line Appears) hypertension, (6th RH Text Line Appears) hemorrhagic stroke, and (7th RH Text Line Appears) cancer of the esophagus, larynx and mouth. (Blue Text Box, LH Text Box, & 1st LH Text Line Appear) For men under age 34 and (2nd LH Text Line Appears) women under age 45, those who do not drink alcohol at all have the lowest death rates. (RH Text Box & 1st RH Text Line Appear) For men 35 or older, those who have five or fewer drinks a week have the lowest death rates. (2nd 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 – (1st blue text box and 1st 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: (2nd 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? (4th 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? (2nd 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 & 1st 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.”7.8The most unhealthy thing about unhealthy alcohol use is that we allow it to remain largely undetected and unaddressed.
  • (Title, Text Box Outline & 1st 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.”7.8The most unhealthy thing about unhealthy alcohol use is that we allow it to remain largely undetected and unaddressed.

Transcript

  • 1. ALCOHOL MISUSE AND DEPENDENCE Dr. Mohammad Shaikhani
  • 2. The problem: Alcohol consumption associated with social, psychological & physical T h e problems constitutes harmful use. C A  G The criteria for alcohol dependence, a more restricted term. E 1/4 of male patients in general hospital medical wards in the UK have a Q u current or previous alcohol problem e s t i o n n a i r e
  • 3. The CAGE Questionnaire T h e C A •Have you ever felt you should CUT down on your drinking? G E •Have people ANNOYED you by criticizing your drinking? Q u •Have you ever felt bad or GUILTY about your drinking? e s • t i Do you ever have a drink first thing in the morning to steady you or help a o hangover? (an EYE opener) n n a i r e
  • 4. CRITERIA FOR ALCOHOL DEPENDENCE : T h e C A Narrowing of drinking repertoire (restriction to 1 type of alcohol as spirits) G E Priority of drinking over other activities (salience) Q u Tolerance of effects of alcohol e s Repeated withdrawal symptoms t i o Relief of withdrawal symptoms by further drinking n n a Subjective compulsion to drink i r Reinstatement of drinking behaviour after abstinence e
  • 5. Aetiology: T h e Availability of alcohol & social patterns of use appear to be the most C A important factors. G E Genetic factors may play some part in predisposition to dependence. Q u The majority of alcoholics do not have an associated psychiatric illness, but e s t a few drink heavily in an attempt to relieve anxiety or depression. i o n n a i r e
  • 6. Diagnosis: T h e Alcohol misuse may emerge during the patient's history, although patients may C A minimise their intake. G E  It may also present via its effects on one or more aspects of the patient's life. Q u Alcohol dependence commonly presents with withdrawal in those admitted to e s t hospital, as they can no longer maintain their high alcohol intake. i o n n a i r e
  • 7. Complications: T h e These are protean and virtually any organ can be involved C A  G Alcohol has replaced syphilis as the great mimic of disease. E Social problems include absenteeism from work, unemployment, marital Q u tensions, child abuse, financial difficulties & problems with the law, such as e s t violence/ traffic offences. i o n n a i r e
  • 8. Psychosocial problems: Depression is common, usually reactive to the numerous social problems which heavy drinking creates. T  Alcohol also has a direct depressant effect. h e  Attempted suicide & completed suicide are often associated with alcohol C A misuse. G E Anxiety is relieved by alcohol. Q u People who are socially anxious may consequently use alcohol in this way & e s t may develop dependence& Conversely, alcohol withdrawal increases anxiety. i o Alcoholic hallucinosis is a rare condition in which alcoholic individuals n n a experience auditory hallucination in clear consciousness. i r Alcohol withdrawal: Symptoms usually become maximal about 2 days after the e last drink& can include seizures ('rum fits'). Delirium tremens is a form of delirium associated with severe alcohol withdrawal with significant mortality& morbidity
  • 9. Brain effects: The familiar features of drunkenness are ataxia, slurred speech, emotional incontinence & aggression. T  h Very heavy drinkers may experience periods of amnesia for events which e occurred during bouts of intoxication, termed 'alcoholic blackouts'. C A  G Established alcoholism may lead to alcoholic dementia, a global cognitive E impairment resembling Alzheimer's disease, but which does not progress if Q u the patient becomes abstinent. e s Indirect effects on behaviour can result from head injury, hypoglycaemia t i o n &portosystemic encephalopathy n a i r e
  • 10. CONSEQUENCES OF CHRONIC ALCOHOL MISUSE : Acute intoxication Emotional & behavioural disturbance T Medical problems: hypoglycaemia, aspiration of vomit, respiratory depression h e Complicating other medical problems C A Accidents&injuries sustained in fights G E Withdrawal phenomena Q u Psychological symptoms: restlessness, anxiety, panic attacks e s t Autonomic symptoms: tachycardia, sweating, pupil dilation, nausea, vomiting i o Delirium tremens: agitation, hallucinations, illusions, delusions n n a Seizures i r e
  • 11. MEDICAL CONSEQUENCES : Neurological Peripheral neuropathy Cerebellar degeneration T h Cerebral haemorrhage e C Dementia A G E Hepatic Q Fatty change,hepatiti, & cirrhosis, Liver cancer u e s t Gastrointestinal Oesophagitis, gastritis i o n Pancreatitis n a Oesophageal cancer i r Mallory-Weiss syndrome e Malabsorption Oesophageal varices Respiratory Pulmonary TB ,Pneumonia
  • 12. MEDICAL CONSEQUENCES : Skin Spider naevi ,Palmar erythema Duypuytren's contractures ,Telangiectasiae T h e C Cardiac Cardiomyopathy A G E Hypertension Q uMusculoskeletal e Myopathy s t i Fractures o n nEndocrine and metabolic a Pseudo-Cushing's syndrome i r e Hypoglycaemia ,Gout Reproductive Hypogonadism Fetal alcohol syndrome Infertility
  • 13. PSYCHIATRIC &CEREBRAL CONSEQUENCES : Depression Alcoholic hallucinosis T Alcoholic 'blackouts' h e Wernicke's encephalopathy: nystagmus, opthalmoplegia, ataxia, confusion C A Korsakoff's syndrome: short-term memory deficits, confabulation G E Q u e s t i o n n a i r e
  • 14. PSYCHIATRIC AND CEREBRAL CONSEQUENCES :Wernicke-Korsakoff syndrome. A rare but important effect of chronic alcohol misuse  This organic brain disorder results from damage to the mamillary bodies, T dorsomedial nuclei of the thalamus & adjacent areas of grey matter. h e  It is caused by a deficiency of thiamin (vitamin B1), which is most commonly C A caused by long-standing heavy drinking & an inadequate diet. G E Without prompt treatment, the acute presentation of Wernicke's encephalopathy Q u (nystagmus, ophthalmoplegia, ataxia & confusion) can progress to the irreversible e s t deficits of Korsakoff's syndrome (severe short-term memory deficits & i o confabulation). n n a In those who die in the acute stage, microscopic examination of the brain shows i r hyperaemia, petechial haemorrhages& astrocytic proliferation. e
  • 15. Management : Advice about the harmful effects of alcohol & safe levels of consumption is often all that is needed. T  h In more serious cases, patients may have to be advised to alter leisure e activities or change jobs if these are contributing to the problem. C A  G Supportive psychotherapy is often crucial in helping the patient make the E necessary changes in lifestyle. Q u Psychological treatment is used for patients who have recurrent relapses e s t &is usually available at specialised centres. i o Support is also provided by voluntary organisations such as Alcoholics n n a Anonymous (AA). i r  If alcohol dependence is suspected, withdrawal syndromes can be e prevented, or treated once established, with benzodiazepines. Large doses may be required (e.g. diazepam 20 mg 6-hourly), tailed off over a period of 5-7 days as symptoms subside.
  • 16. Management : Prevention of the Wernicke-Korsakoff complex requires the immediate use of high doses of thiamin, which may be given parenterally  There is no treatment for Korsakoff's syndrome once it has arisen. T The risk of side-effects, such as respiratory depression with benzodiazepines & h e anaphylaxis with B1, is small when weighed against the risks of no treatment. C A  E Disulfiram (200-400 mg daily) can be given as a deterrent to patients who have G difficulty resisting the impulse to drink after becoming abstinent. Q u  It blocks the metabolism of alcohol, causing acetaldehyde to accumulate. When e s t alcohol is consumed, an unpleasant reaction follows with headache, flushing and i o n nausea. n a  Disulfiram always an adjunct to other treatments,esp psychotherapy. i r e Acamprosate (666 mg 8-hourly) maintain abstinence by reducing the craving for alcohol. Only rarely are antidepressants required; depressive symptoms, if present, usually resolve with abstinence. Antipsychotics as chlorpromazine required for alcoholic hallucinosis.
  • 17. Unhealthy Alcohol Use Is a Significant Public Health Problem In the United States (per year) • 85,000 alcohol-related deaths • Substantial disability from consequences of alcohol use Alcohol Use Among Americans Abusive or dependent 10% Risky - 30% Low-risk - 30% Abstinent - 30%
  • 18. What is the Difference Between Risky Alcohol Use and Alcohol Abuse? Risky Alcohol Use Women 7+ drinks/week 3 drinks/occasion Men 14+ drinks/week 4 drinks/occasion No Alcohol Related Consequences – YET! Alcohol Abuse Recurrences in the last 12 months of: • Failure to fulfill major obligations • Related legal problems • Alcohol use in hazardous situations • Related social or interpersonal problems Source: Saitz R. Unhealthy Alcohol Use. NEJM. 2005;352:596-607.
  • 19. What Determines Alcohol Dependency? Those with alcohol dependency suffer clinically significant impairment or distress in the presence of three or more of the following: 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 Source: Saitz R. Unhealthy Alcohol Use. NEJM. 2005;352:596-607.
  • 20. Moderate Alcohol Use Has Some Health Benefits, But It Affects People Differently Possible Benefits Possible Harmful Effects (Varied based on age, sex, genetics) Liver disease  Risk of ischemic heart disease Pancreatitis Motor vehicle accidents  Risk of ischemic stroke Gun-related trauma Hypertension Hemorrhagic stroke Cancer Lowest Mortality Rates Abstinence Low-Risk Use Men <34 Men >35 <5 drinks/week Women <45 Women >45 <2 drinks/week Source: Saitz R. Unhealthy Alcohol Use. NEJM. 2005;352:596-607.
  • 21. How Does A Person Know If His/Her Alcohol Use is Unhealthy? CAGE (4 questions) 1. Have you felt you should cut down? 2. Have people annoyed you by criticizing your drinking? 3. Have you felt bad or guilty? 4. Do you drink first think in the morning? 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.
  • 22. The AUDIT Test Includes 10 Questions with Multiple Choice Answers Scaled 0 to 4 AUDIT 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? Unhealthy Use Score of 8 or more 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.
  • 23. Nine Steps to Help Prevent Long-Term Disability from Unhealthy Alcohol Use Prevention requires: • Intervention • Tailored treatment plans • Supportive follow-up 1. Gather information 6. Know local referral options 2. Express concern 7. Reinforce self worth 3. Provide feedback 8. Assist with a plan 4. Express empathy 9. Follow up 5. Offer help 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.