The document defines key terms related to substance use such as abuse, misuse, dependence, tolerance, intoxication, withdrawal, and co-dependence. It also summarizes the types of alcoholism including alpha, beta, gamma, delta, and epsilon alcoholism. The effects of alcohol include impacts on neurochemistry through dopamine, GABA, NMDA receptors. Alcohol is absorbed in the stomach and small intestine and metabolized in the liver through oxidation.

1. Important definitions
• Abuse: Use of any drug, usually by self-administration, in a
manner that is not approved by social or medical patterns.
• Misuse: Similar to abuse, but usually applies to drugs prescribed
by physicians that are not used properly.
• Dependence: repeated use of a drug or chemical substance,with
or without physical dependence.
Tolerance: phenomenon in which, after repeated use, a drug
produces a decreased effect or increasingly larger doses are
required to to obtain the effect observed with the previous/original
dose.
•

2. Important definitions
Intoxication: a reversible syndrome caused by a specific
substance, that affects one or more of the following mental
functions: memory, orientation, mood, judgement, and
behavioural, social or occupational functioning.
•
Withdrawal: a substance specific syndrome that occurs, after
stopping or reducing the substance that has been used
regularly over prolonged period. It is characterised by
physiological signs and symptoms in addition to psychological
changes like disturbances in thinking, feeling or behaving. Also
known as abstinence or discontinuation syndrome.
•

3. Important definitions
Cross tolerance: refers to the ability of one drug to be
substituted for another, each usually producing the same
physiological and psychological effect. Also known as cross-
dependence.
•
Co-dependence: term used to refer to family members
affected by or influencing the behaviour of the substance
abuser.
•
Enabling: the act of facilitating the abuser's addictive
behaviour. Also includes the unwillingness of a family member
to accept addiction as a medical-psychiatric disorder or to
deny that the person is abusing.
•

4. Important definitions
Denial: The family member often behave as
the substance use that is causing obvious
problems, are not really problems.
if•
Neuroadaptation: neurochemical or
neurophysiological changes in the body that
result from repeated administration of a drug.
•

5. Alcohol Use Disorder
Dr Priyal Desai
2nd year resident, Dept. Of Psychiatry

6. Alcoholism
•
Alcoholism is characterized by:
A prolonged period of frequent, heavy alcohol use.
The inability to control drinking once it has begun.
Physical dependence manifested by withdrawal•
symptoms when the individual stops using alcohol.
Tolerance, or the
achieve the same
A variety of social
hol use.
need to use
effects
and/or legal
more and more alcohol to
problems arising from alco

7. Types of liquor
Ethyl alcohol (ethanol) is the commonest form of alcohol
used as a beverage.
A single drink is usually 12g of ethanol.
Country English
Desi
Tharra
Taadi
Mosambi
Narangi
Mahua
Anguri
Kaju
Fenny
Laththa
Beer(5%)
Whiskey(40-45%)
Wine (12%)
Vodka(40%)
Rum (40%)
Gin(42%)
Tequilla(38-40%)
Champagne(10-12%)

8. Statistics
In Asia, India is the highest consumer
whiskey(40%).
of•
For India, out of a total population of 132 crores:•
-approx. 40 crores (30%) drink alcohol regularly
-4 crores (3% of total population) are alcoholics
States that have banned the use of alcohol: Gujarat,
Manipur, Nagaland, Bihar and UT Lakshwadeep.

9. Epidemiology
Race: whites and Hispanics have higher
blacks have lower
chances,•
Gender: males>females•
Region and urbanisation: < in western countries
more in large metropolitan cities(56%)than non-
metropolitan (46%)
•
Education: higher in college degree students than
people with less than high school education
•

10. Standard drinks
• A standard drink is defined as 3IU of alcohol. It is different in
quantity for different types of drinks. For India, one
corresponds to 10ml of absolute alcohol.
standard drink
• Vodka, Gin, Tequilla, Rum and whiskey: 30 ml
• Beer: 330 ml (regular)
• Champagne: 100ml
• Wine: 125 ml
• Spirits : 30 ml

11. Definitions
or safe pattern of drinking:Normal•
-not more than 6 IU per day
-not more than 21 IU per week
Not more than 5 days per week
Binge drinking : pattern of drinking characterised•
by drinking more than the intended quantity
lasting for more than the intended time.

12. Etiology
Social factors•
Religious factors•
Psychological factors•
Genetic factors•

13. Etiology (cont.)
Psychological theories:use of alcohol to reduce•
tension and psychological pain, and feel power
However, in high doses, especially at falling
blood alcohol levels, most muscle tensions and
nervousness are increased.
•
Psychodynamic theories:•

14. Etiology (contd.)
Behaviour theories: rewarding effects of alcohol•
Sociocultural theories: Jews, Irish, 40% risk of
becoming alcoholic due to these.
•

15. Types of alcoholism
Alcoholism is classified in various ways•
addiction, can quit, no withdrawal symtoms
can quit, withdrawal seen
Alpha Earliest stage, to relieve pain, can control drinking
Beta
Heavy drinkers, drink daily, physical symptoms, no
Gamma
Loss of control in drinking, physical dependence,
Delta Physical dependence, withdrawal seen, can't quit
Epsilon
Final stage of drinking, continual and insatiable urge
to drink (craving) , compulsive drinking.

16. Types of alcoholism
• Anti social : early onset, predominantly men, poor
prognosis, close relation with anti social personality
• Developmentally cumulative: primary tendency for alcohol
abuse that is exaggerated with cultural expectations.
• Negative-affect alcoholism: more common in women than
men, for mood regulations and to ease relations
• Developmentally self-limited alcoholism: frequent bouts of
consuming large quantities of alcohol, become less
frequent with age and responsibility

17. Types of alcoholism-
dependence
Type A-late onset, less childhood risk factors,
relatively less chances for dependence, few
alcohol-related problems.
•
Type B- early onset, more childhood risk factors,
severe dependence, strong family history, long
history of alcohol abuse and treatment, more
alcohol related health problems.
•

18. Types of alcoholism
Young adult -32%, largest subtype, average age is 24 yrs, rarely seek
help, drink less frequently, more chances of binge drinking.
•
Young anti-social- 21% They are 26 years old, on average. More than
half have antisocial personality disorder, start drinking at 15 and became
alcoholics by 18 -- earlier than other subtypes. They are more likely to
have other substance use too
•
Functional: 19%, middle-aged, working adults with stable relationships,
educated, and higher incomes. They tend to drink every other day, upto
five or more drinks on drinking days.
•
Immediate familial:19%, half have close relatives who are alcoholics.
Alcoholics in this subtype typically began drinking by 17 and became
alcoholics in their early 30s.
•
Chronic severe: rarest subtype, accounting for about 9% of U.S.
alcoholics. This subtype mainly includes men, has the highest divorce
rate, and frequently includes users of illicit drugs.
•

19. Psychiatric co-morbidities
Mood disorders: 40-50% meet criteria for major
depressive disorder
•
Anxiety disorders: 25-50% with AUD meet
criteria for anxiety disorder
•
Suicide: 13% chances of committing a suicide•

20. Neurochemical effects
of alcohol
Alcohol has major effects on most neurochemical
systems, with opposite actions during intoxication
and withdrawal.
•
Intoxication and subsequent craving involve
changes in dopamine, with effects on the
pleasure centers
•
Alcohol also causes an increase in the
concentration of serotonin in the synapse
upregulates serotonin receptors.
•
and

21. Neurochemical effects
of alcohol
Effects of alcohol, especially actions on the
GABA-receptor (GABA), enhance the acute
sedating, sleep-inducing, anticonvulsant, and
muscle-relaxing properties of alcohol
•
For the NMDA receptors, it has dampened
effects during intoxication and heightened activity
during alcohol withdrawal.
•

22. Absorption
Absorption:About 10% of alcohol ingested is absorbed into the
stomach, rest 90% is absorbed in the 2nd part of duodenum.
•
In most cases, higher alcohol concentration, faster is the rate of
absorption. However, beyond a certain concentration, the rate
decreases due to delayed passage of alcohol from stomach to
small intestine.
•
Maximum absorption rate is seen with a beverage containing
approx. 20-25% alcohol, and rate decreases with beverages
containing 40% or more alcohol
•
Absorption increases if the drink is taken empty stomach and vice
versa.
•

23. Absorption
Peak blood concentration is reached within 30-90•
minutes, usually within 45- 60 minutes.
Alcohol is uniformly absorbed
hence tissues containing high
absorb more alcohol.
in body water
proportion of water
•
The intoxicating effects are higher when the
blood alcohol is rising than when it is falling.
(Mellanby effect)
•

24. Metabolism
• 90% alcohol is metabolised through oxidation in
remaining is excreted unchanged by lungs and
kidneys.
liver,
• Rate of metabolism is 10-34mg/dL per hour.
• Alcohol is metabolised by two enzymes: alcohol
dehydrogenase(ADH) and aldehyde dehydrogenase.
• Alcohol is converted into acetaldehyde catalysed by
ADH.

25. Metabolism
Acetaldehyde is a toxic substance and causes•
Hence it is converted into acetic acid catalysed
by aldehyde dehydrogenase.
•
Women have lower levels of ADH which could be
a reason for their intoxication more than men
after drinking the same amount of alcohol.
•

26. Acetyl COA is then converted to water and carbon
dioxide that is released via the kidneys and lungs.

27. Blood alcohol
concentration(BAC)
It is the
units of
alcohol
percentage of ethanol in the blood in•
alcohol per volume of blood
per mass of blood.
or mass of
The blood alcohol legal limit
alcohol in blood
in India is 0.03%•
Impairments acc to BAC•

29. Intoxication
Acc. To DSM-V:•
Recent ingestion of alcohol, maladaptive
behaviour and one of the following:
•
Slurring of speech, in coordination,ataxic
gait,nystagmus, impaired attention concentration,
stupor or coma
•

30. Effect of various
concentrations of alcohol:
• At higher levels, the following can be manifested:
• 20-30mg/dL-slowed motor performance and decreased thinking
ability
• 30-80mg/dL-increased motor and cognitive deficits
• 80-200mg/dL- in coordination and judgement errors, mood lability
• 200-300mg/dL- nystagmus, slurring of speech, blackouts
• >300mg/dL- impaired vital signs
• >400mg/dL- respiratory failure, coma, death

31. Withdrawal
• Cessation of alcohol use which was heavy and prolonged.
• Classic sign of withdrawal is tremulousness.
Symptoms and signs
last intake
autonomic hyperactivity
withdrawal)
Duration from
6 to 8 hours
Tremulousness, irritability, GI symptoms,
8 to 12 hous Psychotic and perceptual abnormalities
12 to 24 hours
Seizures (can occur within first 72 hours of
Up to 72 hours Delirium tremens

32. Treatment
• Withdrawal seizures: stereotyped, GTCS, more than one
seizure can occur within 3-6 hours of first seizure.
• Status epilepticus is rare (<3%)
• Treatment does not require anti-convusants, however most
patients receive them, to be on the safer side.
• Benzodiazepines are primarily used to control withdrawal
symptoms.
• Drugs like carbamazepine can also be used in daily doses
of 800mg.

33. Delirium Tremens
Alcohol withdrawal tremors with delirium are a serious
medical emergency.
•
Essentially DT is seen within 1 week after he stops or•
decreases drinking.
heavy drinking.
Begins generally after 5-15 yrs of
Best treatment is prevention.•
BZD chlordiazepoxide (50-100mg every 4 hrs)•
Lorazepam IV•
Correct dehydration•

34. hrs
Drug symptoms dose
Chlordiazepoxide Tremors and
tremulousness
Extreme
agitation
25-100 mg every 4-6
0.5mg/kg at
12.5mg/min IV
Diazepam Mild to
moderate
agitation
Withdrawal
seizures
5-20mg every 4-6
hrs
0.15 mg/kg at
2.5mg/min
Lorazepam Hallucinosis
Delirium
tremens
2-10 mg every 4-6
hrs
0.1mg/kg at 2mg/min
IV

35. Other effects
Blackouts: it is characterized by memory
impairment for the period when a person
drinking heavily and was awake.
•
was
Sleep impairments: alcohol helps in sleeping
quickly, but if it exceeds 2-3 drinks per evening,
sleep pattern is impaired.
•
Cerebellar degeration: unsteady gait, nystagmus•
Peripheral neuropathy: tingling numbness, pin
pricking sensations, cotton-wool sensations
•

36. CNS effects
Wernickes encephalopathy: Caused by the
deficiency of vitamin B1(thiamine that helps
conduction of axon potential along the axon
in synaptic transmission.
•
in
and
Manifested as ataxia, ophthalmoplegia,
confusion.
•
Treatment: 100mg BD or TDS for 1-2 weeks•

37. CNS effects
Korsakoff’s syndrome: Chronic amnestic disorder
that follows Wernicke’s encephalopathy.
•
Cardinal features are: irreversible damage,
impaired anterograde memory with
confabulations.
•
Treatment: thiamine
months.
100mg BD or TDS for 3-12•
Hardly recover fully,
improve.
but cognitive functions may•

38. Others
Marchia Fava Bignami syndrome: progressive
neurological disease of alcoholism characterised
by corpus callosum demyelination and necrosis.
•
Fetal Alcohol syndrome: alcohol intake in women
who are pregnant or lactating. Alcohol inhibits
intrauterine growth and postnatal development
leading to microcepaly, malformations of heart,
limbs and lungs.
•