Alcohol withdrawal

1. Alcohol Use Disorders
Patterns & Management
Jaison Joseph

2. Alcohol-A social Burden……

3. Key facts
 The harmful use of alcohol results in 2.5 million deaths
each year
 320 000 young people between the age of 15 and 29 die
from alcohol-related causes, resulting in 9% of all deaths
in that age group
 Alcohol is the world’s third largest risk factor for disease
burden
 Alcohol is associated with many serious social and
developmental issues, including violence, child neglect
and abuse, and absenteeism in the workplace

4.  Taxes generated from alcohol production is around Rs.25,000 crores
& consumption is 2 litres per person a year
 Kerala, Punjab, Andhra Pradesh, Goa and the North-Eastern States
have a much higher proportion of alcohol consumption
 Four states - Gujarat, Mizoram, Manipur and Nagaland - have
enforced prohibition
(Indian Alcohol Policy Alliance (IAPA).Newsletter Vol. I January-March 2009)

5.  Prevalence estimates Males Females
Alcohol use disorders (15+ years) 3.47% 0.42%
( Data source: United Nations, data range 1990–2006. Global Status Report on Alcohol and Health
2011(http://www.who.int/globalatlas/alcohol)
 The prevalence of alcohol use is still low in India compare to the global
perspective but Studies by Alcohol & Drug Information Centre (ADIC)-India
shows an alarming increase in alcohol consumption
(Indian Alcohol Policy Alliance (IAPA).Newsletter Vol. I January-March 2009)
Alcohol Consumption in India

6. It may imminent …
The average age of initiation to alcohol in Kerala which was 19 years
in1986 has come down to 14 years in 2006
(Rekha .Alcohol use on the rise in India. The Lancet, Volume 373, Issue 9657, Pages 17 - 18, 3 January 2009)
Alcohol Consumption in India
Current trends……

7. A 1904 advertisement labeling alcoholism a "disease".
(WHO (2004).Neuroscience of psychoactive substance use and dependence. Switzerland)

8. Alcohol - a friend or a foe?
Use of alcohol
from ‘water of life’ to ‘addiction’
A friend ? Alcohol A foe !
wines and beers
wondrous potions
“Hard alcohol”
“water of life”-
Whiskey
Heavy drinking –
Addiction
WHO
Harmful alcohol use
4.5% of the global
burden of disease
Hebrew Bible
Vedas of India Distillation Era Benjamin Rush

9. F10.-Mental and behavioural disorders due to use of
Alcohol
F10.0 Acute intoxication
F10.1 Harmful use
F10.2 Dependence syndrome
F10.3 Withdrawal state
F10.4 Withdrawal state with delirium
F10.5 Psychotic disorder
F10.6 Amnesic syndrome
F10.8 Other mental and behavioural disorders
F10.9 Unspecified mental and behavioural disorder
I C D 10 & Alcohol

10. Case vignette - I
Mr.XY,26yr,unmarried,R/o UP
C/o- having severe anxiety, irritability, restlessness
and sleep disturbances if he missed his drink
HOPI- 1 beer@eve,2-3 beer/day, cocktail with
brother 350 ml/day- 1-2 bottle whisky /day
(brothers death, marriage break up)
MSE- Uncomfortable, anxious, helpless
Diagnosis & Management ????

11. Case vignette - II
Mr. RK, 45yr, separated, clerk
C/o- confused and agitated state (emergency)
HOPI- alcohol intake since 25 years
30ml/wk@20 yr ------180/day 30 yr----No problems even if
abstinent for 3 days
750ml whisky /day@ 40yr---- blackouts , haematemesis,
melaena, DM, 2 seizure episode in 2 & 5day abstinent @
43 yr& 45yr
P/E - coarse tremors,pallor, signs of dehydration, diaphoresis,
tachycardia, blood pressure of 110/60 mmHg and
respiratory rate of 24/minute.
MSE- Impairment in perception, cognition
Diagnosis & Management ????

12. ALCOHOL
• Derived from the Arabian term, ‘al-kuhul’- ‘finely
divided spirit’
• Classified as a ‘food’
• A natural substance formed by reaction of fermenting
sugar with yeast spores.
• Common form of alcohol– Ethyl alcohol (ethanol)
• Chemically – C2 H5 OH (ETOH)

13. ALCOHOL CONTENT

14. Standard drink
One Standard Units of alcohol = 10ml of absolute alcohol

15. Patterns of drinking
• BINGE DRINKER is one who drinks alcoholic
beverages with the primary intention of becoming
intoxicated by heavy consumption of alcohol over
a short period of time.
• HEAVY DRIKER is one who consumes 5 or more
drinks per occasion on 5 or more days in the past
30 days.

16. ETIOLOGY
• PSYCHOLOGICAL THEORIES
– Reduce tension
– Increase feelings of power
– Decrease the effects of psychological pain
– Decrease the feelings of nervousness
– Helps to cope with stress
– Enhanced feeling of well being
– Improves ease of interactions

17. ETIOLOGY
• PSYCHODYNAMIC THEORIES
– To deal with self punitive harsh super-egos
– Decrease unconscious stress levels.
– Fixation in the oral stage of development.
• BEHAVIORAL THEORIES
– Expectations about the rewarding effects of drinking
– Cognitive attitudes toward responsibility for one's
behavior
– Reinforcement after alcohol intake

18. ETIOLOGY
• SOCIOCULTURAL THEORIES
– Extrapolations from social groups.
– Alcoholism in parents
– Childhood history of;
• ADHD
• Conduct disorder
– Personality disorder
– Cultural factors

19. ETIOLOGY
• GENETIC THEORIES
– The rate of alcohol problems increases with the
number of alcoholic relatives,
– Twins -- 60 percent
– Adoption studies– increased risk, if biological parents
are alcoholics.
– Animal studies

20. Factors leading to Alcohol use/Abuse

21. EFFECTS OF ALCOHOL
• Induce a general, non selective reversible
depression of the CNS
• 20% of alcohol– absorbed directly and
immediately by the stomach wall.
• 80% absorbed slowly by intestine and found in
all tissues.

22. • METABOLISM
– 90% through oxidation
in the liver
– Metabolized by two
enzymes
• Alcohol dehydrogenase
(ADH)
• Aldehyde
dehydrogenase
Alcohol
Acetic acid
Acetaldehyde
EFFECTS OF ALCOHOL
Co2 + H2O

23. EFFECTS ON THE BRAIN
• At 0.05% in the blood; thought,
judgment are loosened
• At 0.1% ; voluntary motor actions
become clumsy
• At 0.2% ; entire motor area of
brain is depressed and emotional
control is also affected
• At 0.3%; confused or become
stuporous
• At 0.4 to 0.5% ; person falls into
coma
Blood alcohol concentration(BAC)
measured in mg alcohol per 100
ml blood (mg%)– Breath
testing
Legal intoxication ranges from 0.1 to 0.15 mcg%
Breath alcohol reading
(mcg%)
BAC (mg%)
0.35 80
0.52 120
0.70 160
0.87 200
1.05 240
1.40 320
1.75 400

24. Alcohol and the Human body
• ..musiqqqMotivation A VAddiction videoAlco

25. Impairment at different blood levels
Level Likely Impairment
20-30 mg/dL Slowed motor performance and decreased thinking ability
30-80 mg/dL Increases in motor and cognitive problems
80-200 mg/dL Increases in incoordination and judgment errors
Mood lability, Deterioration in cognition
200-300 mg/dL Nystagmus, marked slurring of speech, and alcoholic
blackouts
>300 mg/dL Impaired vital signs and possible death

26. PHYSIOLOGICAL EFFECTS
LIVER
• Alcohol use, result in
accumulation of fats and
proteins -- appearance of a
fatty liver.
• Alcoholic hepatitis and
hepatic cirrhosis.
• Ascites
• Severe cases can lead to
Hepatic encephalopathy

27. PHYSIOLOGICAL EFFECTS

28. Gastrointestinal system
• Development of esophagitis, gastritis,
achlorhydria, and gastric ulcers.
• Esophageal varices
• The rupture of the varices is a medical emergency
• Disorders of the small intestine
• Pancreatitis, pancreatic insufficiency, and
pancreatic cancer
PHYSIOLOGICAL EFFECTS

29. Acute intoxication (F10.0)
• Occurs at blood alcohol levels between 100
and 200 mg/dl
• Death reported at 400 to 700 mg/dl

30. Alcohol intoxication - Diagnostic criteria
• Recent ingestion of alcohol
• Clinically significant maladaptive behavioral or
psychological changes that developed during, or shortly
after, alcohol ingestion
• One (or more) of the signs, (during, or shortly after use)
– slurred speech
– incoordination
– unsteady gait
– nystagmus
– impairment in attention or memory
– stupor or coma
• Not due to a general medical condition and by another
mental disorder

31. Harmful use (F10.1)

32. Dependence Syndrome (F10.2)
(a) A strong desire or sense of compulsion to take the substance;
(b) Difficulties in controlling substance-taking behaviour in terms of its onset,
termination, or levels of use;
(c) Physiological withdrawal state
(d)Tolerance : increased doses of the psychoactive substance are required in order
to achieve effects originally produced by lower doses
(e)Progressive neglect of alternative pleasures or interests ,increased amount of
time necessary to obtain or take the substance or to recover from its effects;
(f)Persisting with substance use despite clear evidence of overtly harmful
consequences, such as harm to the liver through excessive drinking
A
n
y
3

33. Withdrawal state (F10.3)
• Withdrawal is the development of physical
or psychological symptoms after the
reduction or cessation of intake of a
repeatedly used substance
• Physical vary with substances
• Psychological (e.g. anxiety, depression, and
sleep disorders) are common

34. Withdrawal syndromes
Tremulousness
(shakes , jitters)
Alcoholic hallucinosis
(horrors)
Withdrawal seizures
(rum fits)
Delirium tremens
(shakes)

35. Alcohol withdrawal
• Classic sign --- tremulousness
develops 6 - 8 hrs after cessation of drinking
• Psychotic and perceptual symptoms (e.g.,
delusions and hallucinations) in 8 to 12 hrs
• Seizures in 12 to 24 hour
• Delirium tremens (DTs) or alcohol withdrawal
delirium during 72 hours

36. Criteria – Alcohol Withdrawal
• Cessation or reduction alcohol use that has been heavy and prolonged.
• Two (or more) of the following, developing within several hours to a
few days after cessation or reduction
– autonomic hyperactivity (e.g., sweating ,tachycardia)
– increased hand tremor
– insomnia
– nausea or vomiting
– transient visual, tactile, or auditory hallucinations or illusions
– psychomotor agitation
– anxiety
– grand mal seizures
• The symptoms cause clinically significant distress or impairment in
social, occupational, or other areas of functioning.
• Not due to a general medical condition or by another mental disorder.

37. Withdrawal Seizures
• Stereotyped, generalized, and tonic-clonic in character
• Often have more than one seizure 3 to 6 hours after the
first seizure
• Status epilepticus :in less than 3% of patients
Treatment
• Benzodiazeines
– Diazepam (Valium)
– Chlordiazepoxide (Librium)
• Carbamazepine : daily dose of 800 mg

38. Alcohol Withdrawal Delirium
• A medical emergency, Most severe form
• Also known as Delirium Tremens (DTs).
• Occurring within 1 week after cessation or
reduction of alcohol
• Usually in patient's 30s or 40s after 5 to 15 years
of heavy drinking
• More in persons with physical illness

39. Criteria – Alcohol Withdrawal Delirium
• Disturbance of consciousness with reduced ability
to focus, sustain, or shift attention
• A change in cognition or the development of a
perceptual disturbance that is not better accounted
for dementia
• Develops over a short period of time (usually
hours to days) and tends to fluctuate during the
day
• Symptoms of autonomic hyperactivity such as
tachycardia, diaphoresis, fever, anxiety, insomnia,
and hypertension

40. Treatment- DTs
• The best treatment for DTs is prevention.
• Patients withdrawing from alcohol should receive a
benzodiazepine
• Chlordiazepoxide 25 – 50 mg every 2 to 4 hours
until they seem to be out of danger.
• Once the delirium appears
– Chlordiazepoxide 50 – 100 mg
– Lorazepam ; oral or parentral (0.1 mg/kg)
• Avoid restraining
• Maintain hydration
• Avoid antipsychotics
• Reassurance

41. Psychiatric disorders
• Alcohol induced
– Mood disorder
– Hallucinosis
– Pathological jealousy/
Othello syndrome

42. Neurological manifestations
• Alcohol dementia
• Wernicke-Korsakoff
syndrome
• Cerebellar degeneration
• Peripheral neuropathy
• Optic neuropathy
(tobacco-alcohol
amblyopia)

43. Wernicke’s Encephalopathy
• Also called alcoholic encephalopathy
• Serious form of thiamine deficiency
• Symptoms : paralysis of the ocular muscles,
diplopia, ataxia, somnolence and stupor
• May clear spontaneously in a few days or weeks
or progress into Korsakoff's syndrome(a chronic
condition)
• Thiamine replacement: 100 mg 2 to 3 times daily
for 2 to 3 weeks

44. Korsakoff’s psychosis
• A syndrome of confusion, loss of recent
memory and confabulations.
• Treatment : Thiamine100 mg 2 to 3 times daily
for 3 to 12 months
• Both disorders together called as Wernicke-
Korsakoff’s psychosis

45. Investigations
• SGOT/SGPT
• Alb/glob reversal
• PT prolonged
• GGT
• Carbohydrate deficient
transferrin (CDT)
• MCV
• BAC
• USS Abdomen
• CT Brain

46. C.A.G.E
• Have you felt you should Cut down on your
drinking ?
• Have people Annoyed you by criticizing on
your drinking ?
• Have you felt bad or Guilty about your
drinking?
• Have you ever had to drink first thing in the
morning to steady your nerves or get rid of
a hangover? ( Eye opener)

47. Alcohol use disorders- Treatment
CORE
• Maximize motivation for abstinence
• Restructure their lives without alcohol
• Minimize relapse
Three steps INTERVENTION
DETOXIFICATION
REHABILITATION

48. Alcohol Use Disorders
Detoxification
• Symptoms develops because the brain has physically
adapted to the presence of a depressant
• Offer rest, adequate nutrition, and multiple vitamins,
especially thiamine
• Benzodiazepines are widely used for its relative safety
– Short-acting drugs (e.g., lorazepam)
– Long-acting substances (e.g., chlordiazepoxide and diazepam)
• If over sedated, skip dose
• Adrenergic receptor antagonists like Propranolol
can also be used

49. Alcohol use disorderAlcohol use disorder
Detoxification Management
• Tab Chlordiazepoxide 100 mg /d
• Inj. B Complex
• Inj.Thiamine 100mcg * 5days
• Lorazepam for sedation If LFT is high
Taper and stop in 2 wks
Treat any associated medical illness

50. Alcohol use disorderAlcohol use disorder
Inpatient treatment
• Tab Chlordiazepoxide 100 mg /d and taper
• Thiamine 100 mg IM first then oral
• IV Fluid
• Haloperidol – low dose for hallucinations
• Inj. Lorazepam for seizures Intravenous 0.1
mg/kg at 2.0 mg/min
• Inj.Diazepam Intravenous 0.15 mg/kg at 2.5
mg/min
Treatment of associated medical illness

51. Alcohol use disorders: Treatment
Anticraving agents
• ACAMPROL-333mg
• TOPIRAMATE 25-
200mg
• BACLOFEN-5-30mg
• LITHIUM-300mg
Deterrants
• DISULFURAM-
250mg
• METRONIDAZOLE

52. Alcohol
Acetic acid
Acetaldehyde
Effects of Disulfiram
• Disulfiram – alcohol reaction
(DER) occur within 5 to 10
minutes of ingestion of alcohol
• Mild reactions occur at blood
levels of 5 to 10 mg/dl
• Symptoms fully develop at 50
mg/dl
– Vomiting, sweating, flushing,
tachycardia, hypotension, blurred
vision, weakness, confusion and
dizziness
• Severe reactions at 125 to 150
mg/dl
– Respiratory depression,
cardiovascular collapse, CHF,
arrhythmias, convulsions and death

53. Psychological interventions
• Motivation
enhancement therapy
• Family therapy-
Codependency
Denial
Enabling
• Group therapy
• Alcohol anonymous
• Individual counselling
– Social skills training
(saying no).
– Problem-solving skills.
– Relaxation training.
– Anger management.
– Cognitive restructuring.

54. REHABILITATION
Three major components:
(1) Continued efforts to increase and maintain
high levels of motivation for abstinence
(2) Work to help the patient readjust to a lifestyle
free of alcohol
(3) Relapse prevention

55. COUNSELING
• To optimize motivation –
– Explore the consequences of drinking,
– Likely future course of alcohol-related life problems
– Improvement that can be expected with abstinence.
• 3 times a week for the first 2 to 4 weeks
• Once a week, for the subsequent 3 to 6 months

56. Relapse Prevention
– Identifies situations in which the risk for relapse is
high.
– Help the patient develop modes of coping to be used
when craving increases
– Remind the patient about the appropriate attitude.
– Rebuild relationships
– Supportive family

57. Stages of Treanstheoretical model of change
Prochaska &
DiClemente, 1983

58. Self Help Groups
“We admitted we were powerless over alcohol—that
our lives had become unmanageable”

59. PREVENTION STRATEGIES
Regulation and Legislation
Product Reformulation and Labeling
Awareness/Prevention/Education

60. Nursing Management
• Health teaching for the client and family
• Decrease co-dependent behaviours among
family members
• Make appropriate referrals for family
members
• Promote coping skills
• Role-play potentially difficult situations
• Focus on the here-and-now with clients

61. NURSING DIAGNOSIS
• Risk for Injury
Disorientation and environmental conditions
interacting with the individual’s adaptive
and defensive resources

62. NURSING DIAGNOSIS
• Imbalanced nutrition less than body
requirement
Use of substances instead of eating

63. NURSING DIAGNOSIS
• Ineffective Health Maintenance
Inability to identify, manage, and/or seek out
help to maintain health

64. Pharmacological Management
 F10.2 Dependence syndrome
Naltrexone , Acamprosate Calcium, Disulfiram (FDA approved)
Topiramate (off label use)
 F10.3 Withdrawal state
Valium (diazepam), Librium (chlordiazepoxide)
Psychosocial interventions
 Brief motivational interventions
 Behavioural approaches : Cue exposure & Contingency management
 Cognitive-behavioural approaches
 Relapse prevention
 Motivational interviewing
 Others like family & marital therapy, person centered therapy, solution focused
therapy etc…

65. Case vignette - I
Mr.XY,26yr,unmarried,R/o UP
C/o- having severe anxiety, irritability, restlessness
and sleep disturbances if he missed his drink
HOPI- 1 beer@eve,2-3 beer/day, cocktail with
brother 350 ml/day- 1-2 bottle whisky /day
(brothers death, marriage break up)
MSE- Uncomfortable, anxious, helpless
Alcohol Dependence Syndrome Currently in Withdrawal State,
Uncomplicated
(F 10.2, F 10.30)
Diagnosis ????

66. Case vignette - I
Mr.XY,26yr,unmarried,R/o UP
C/o- having severe anxiety, irritability, restlessness
and sleep disturbances if he missed his drink
HOPI- 1 beer@eve,2-3 beer/day, cocktail with
brother 350 ml/day- 1-2 bottle whisky /day
(brothers death, marriage break up)
MSE- Uncomfortable, anxious, helpless
First day
Oral diazepam (40 mgs/day), thiamine (100 mgs/day)and multi
vitamins
Second day
Diazepam 50mgs/ day (due to tremors and anxiety)
Fourth day
Diazepam (gradually reduced)
Stopped on the 8th
day (Improvement in withdrawal symptoms)
Supportive psychotherapy and motivational counselling
Maintenance treatment : Acamprosate (333 mgs) 4 tabs / day
Management ????

67. Case vignette - II
Mr. RK, 45yr, separated, clerk
C/o- confused and agitated state (emergency)
HOPI- alcohol intake since 25 years
30ml/wk@20 yr ------180/day 30 yr----No problems even if
abstinent for 3 days
750ml whisky /day@ 40yr---- blackouts , haematemesis,
melaena, DM, 2 seizure episode in 2 & 5day abstinent @
43 yr& 45yr
P/E - coarse tremors,pallor, signs of dehydration, diaphoresis,
tachycardia, blood pressure of110/60 mmHg and
respiratory rate of 24/minute.
MSE- Impairment in perception, cognition
Alcohol Dependence Syndrome with withdrawals (complicated by
delirium tremens and withdrawal seizures)
( F 10.2, F 10.41)
Diagnosis ????

68. Case vignette - II
Mr. RK, 45yr, separated, clerk
C/o- confused and agitated state (emergency)
HOPI- alcohol intake since 25 years
30ml/wk@20 yr ------180/day 30 yr----No problems even if
abstinent for 3 days
750ml whisky /day@ 40yr---- blackouts , haematemesis,
melaena, DM, 2 seizure episode in 2 & 5day abstinent @
43 yr& 45yr
P/E - coarse tremors,pallor, signs of dehydration, diaphoresis,
tachycardia, blood pressure of110/60 mmHg and
respiratory rate of 24/minute.
MSE- Impairment in perception, cognition
First days
IV fluids
Sliding scale plain insulin
Thiamine 100 mg IV on the first day, 50 mg IM/d over the next 3
days and then maintained on oral thiamine (along with other
vitamin supplements)
Lorazepam 4 mg slow IV stat, followed by oral lorazepam 2 mg
q.i.d.
Next 3 days
Sensorium improved; able to identify family members correctly
and was able to remember things properly
Lorazepam was gradually tapered off; by 7th day (stopped)
Cognitive therapy
Tab. Acamprosate (333 mg) 2tabs t.i.d.
Management

69. Take Home Message
18th
Century
Pejorative notion on Alcohol
use
Harmful alcohol use
 2.5 million deaths
every year
Can you try or ready to do an another attempt…
Am sure you can also do it because many people have
done it …..
After some trial and error eventually you will be on
track….