Alcohol is a major public health concern, contributing to over 2.5 million deaths per year globally. It has a long history of use dating back thousands of years. Alcohol dependence is characterized by impaired control over drinking and continued use despite consequences. Treatment involves managing withdrawal, brief interventions, rehabilitation programs, medications, and counseling. Physicians play an important role in identifying alcoholism and guiding treatment.

1. Alcohol and Alcoholism
PRESENTER-
DR. PRADIP KATWAL
MODERATOR-
DR. THOMAS JOHN

2. WHY ALCOHOL IS
A PUBLIC HEALTH Causal factor in more than 60
CONCERN? major types of diseases and
injuries
Results in approximately 2.5
million deaths each year.
 4% of all deaths worldwide are
attributable to alcohol.
World Health Organization (2008b). The global burden of disease: 2004
update. Geneva (http://www.who.int/evidence/bod, accessed 28
November 2010

3. HISTORY OF ALCOHOL
 Alcoholic beverages in the
Indus valley civilization.
 These beverages were in use
between 3000 BC - 2000 BC.
 Sura, a beverage brewed from
rice meal, wheat, sugar cane,
grapes, and other fruits, was
popular among
the warriors and the peasant
population.
 Sura is considered to be a
favorite drink of Indra.

4. Devotees drink traditional alcohol flowing from the mouth of a statue of
the deity Swet Bhairav during the second day of the week long Indra Jatra
festival in Nepal

5. When the pregnant woman gives birth to the child, the family members
serve best quality of aerakm ( Alcohol) or chhyang (Fermented liquor) to
her. If the economic status is good, they serve warm alcohol mixed with
one teaspoon of ghee.
They believe it helps to restore the energy and as the drink makes her
intoxicated it relives her from exhaustion.

6. Present scenario
A total of 1068 individuals successfully completed the study. According to DSM-
IV, drinkers were classified as follows: No alcohol problem (n=562; 59.5%),
alcohol abusers (n= 78; 8.3%) and alcohol dependent (n=304;
32.2%). The prevalence of hazardous drinker was 67.1%

7. There were 55 subjects in the study. Half of them were between 35-45 years age
group and one fourth among them were female. There were more than 88%
physicians consuming alcohol for more than 10 years. One third used to
preferred whisky as their favorites drink.

8.  Alcohol are derivatives of
What is alcohol ? hydrocarbons
 One or more of the hydrogen atoms
have been replace by a hydroxyl (-
OH) functional group
 Ethyl alcohol - for which the more
scientific name is ethanol - is the
substance that we find in beverages.
 Formed through fermentation of a
variety of products including grain
such as corn, potato mashes, fruit
juices, and beet and cane sugar
molasses

9. ALCOHOLIC BEVERAGES
 Raksi 25%
 Jand or
Chhang12%
 Tongba 5.5%
 Beer
 Vodka
 Rum
 Gin
 Wine
 Whiskey

10. ALCOHOL
10–15 g of Equivalent to
115 mL (4 oz) of
ethanol
nonfortified wine
(a standard
drink)
43 mL (1.5 oz) (a
shot) whisky, gin,
or vodka
340 mL (12 oz) of
beer

11. PHYSIOLOGY
Absorption Rate of absorption is
increased
mouth and  Carbonated
esophagus (in
beverages
small amounts)
 Absence of
stomach and
proteins,
large bowel (in fats, or
modest carbohydrate
amounts) s
proximal  Dilution of
portion of the ethanol (20%
small intestine by volume).
(the major site).

12. Metabolism
• Two pathways
– Alcohol dehydrogenase
– Microsomal ethanol oxidizing system

13. Breath analyser  Between 2% and 10% of ethanol
is excreted directly through the
lungs, urine, or sweat.
 The concentration of the alcohol
in the alveolar air is related to
the concentration of the alcohol in
the blood.
 As the alcohol in the alveolar air
is exhaled, it can be detected by
the breath alcohol testing device.

14. Do alcohol give
energy?
• Alcohol supplies calories (a drink
contains 70–100 kcal),
 Devoid of nutrients such as
minerals, proteins, and vitamins.
 Interfere with absorption of
vitamins in the small intestine
 Decreases their storage in the
liver

15. Alcohol on neurotransmitter systems
neurotransmitt acute alcohol
er intoxication withdrawal
Gamma
aminobutyri
c acid
(GABA)
N-methyl-d-
aspartate
(NMDA)
excitatory
glutamate
receptors

16. .

18. Behavioral Effects
Effects of Blood Alcohol Levels in the Absence
of Tolerance
Blood Level, g/dL Usual Effect
0.02 Decreased inhibitions, a slight
feeling of intoxication
0.08 Decrease in complex cognitive
functions and motor
performance
0.20 Obvious slurred speech, motor
incoordination, irritability, and
poor judgment
0.30 Light coma and depressed vital
signs
0.40 Death

19. Tolerance
 Metabolic or pharmacokinetic tolerance –
 30% increase in the rate of hepatic ethanol metabolism
 Cellular or pharmacodynamic tolerance –
 neurochemical changes that maintain relatively normal
physiologic functioning despite the presence of alcohol.
 Learned or behavioral tolerance –
 adapt their behavior so that they can function better than
expected under influence of the drug

20. The Effects of Ethanol on Organ Systems

21. Nervous System
 Blackout(35%)
 Disturbed sleep
 Impaired judgment and coordination.
 Hangover syndrome

22.  Peripheral neuropathy(10%)
 Cerebellar degeneration or atrophy(1%)
 Wernicke's (ophthalmoparesis, ataxia, and
encephalopathy)
1 in 500
alcoholics
 Korsakoff's (retrograde and anterograde
amnesia) syndromes

23. The Gastrointestinal System
• Esophagus and Stomach
 Hemorrhagic gastritis
 Mallory-weiss lesion

24. • Pancreas and Liver
Acute pancreatitis
Fatty liver
Alcohol-induced hepatitis
Cirrhosis

25. Cancer
• Breast cancer 1.4-fold.
• Oral and esophageal cancers approximately threefold
• Rectal cancers by a factor of 1.5
These consequences may result directly from cancer-
promoting effects of alcohol and acetaldehyde or
indirectly by interfering with immune homeostasis.

26. Hematopoietic System
 Increased red blood cell size (mean corpuscular volume)
 Folic acid deficiency.
 Decrease production of white blood cells
 Thrombocytopenia.

27. Reproductive system
 Amenorrhea Increase sexual
 Ovarian size drive
decrease Decrease erectile
 Infertility capacity
(absence of
corpora lutea) Testicular
 Increased risk of
atrophy
spontaneous
Ejaculate volume
abortion
 Fetal alcohol decreases
syndrome Lower sperm
count

28. Definitions
• Alcoholism - patients with alcohol problems
• "... a primary chronic disease with genetic psychosocial and
environmental factors ... often progressive and fatal ... characterized
by impaired control over drinking, preoccupation with the drug alcohol,
use of alcohol despite future consequences, and distortions of thinking
most notably denial...."
*National Council on Alcoholism and Drug Dependence and the
American Society of Addiction Medicine

30. • Abstainers-
– individuals who consume no alcohol
• Low risk drinking
– number of drinks consumed daily that places an adult
at low risk for alcohol problems
• At-risk drinking
– a level of alcohol consumption that imparts health
risks
Risk drinking is defined as an average of 15 or more standard
drinks per week or 5 or more on an occasion for men and 8 or
more drinks weekly or 4 or more on an occasion for women and
people older than 65 years of age.

31. Moderate drinking?

32. Alcohol dependence
“A cluster of behavioural, cognitive, and physiological phenomena that
develop after repeated alcohol use and that typically include a strong
desire to consume
Difficulties in controlling its use
 Persisting in its use despite harmful consequences
A higher priority given to alcohol use than to other activities and
obligations
Increased tolerance
And sometimes a physical withdrawal state

33. Alcohol abuse
• Alcohol abuse is defined as repetitive problems with
alcohol in any one of four life areas
– social
– interpersonal
– Legal
– occupational
• repeated use in hazardous situations such as driving
while intoxicated in an individual who is not alcohol
dependent.
The criteria are based on the Diagnostic and Statistical Manual of Mental Disorders,
fourth edition, text revision (DSM-IV-TR). The table is adapted from the DSM-IV-TR
and information from the National Institute on Alcohol Abuse and Alcoholism.

34. Identification of the Alcoholic
• Questions about alcohol problems
• laboratory test
• The two blood tests with 60% sensitivity and
specificity for heavy alcohol consumption are
– glutamyl transferase (GGT) (>35 U)
– carbohydrate-deficient transferrin (CDT) (>20 U/L or >2.6%);
• Other useful blood tests include high-normal MCVs
(91 m3) and serum uric acid (>416 mol/L, or 7 mg/dL).

35. The Alcohol Use Disorders Identification Test
(Audit)
Item 5-Point Scale (Least to Most)
1. How often do you have a drink Never (0) to 4+ per week (4)
containing alcohol?
2. How many drinks containing alcohol 1 or 2 (0) to 10+ (4)
do you have on a typical day?
3. How often do you have six or more Never (0) to daily or almost daily (4)
drinks on one occasion?
4. How often during the last year have Never (0) to daily or almost daily (4)
you found that you were not able to stop
drinking once you had started?

36. 5. How often during the last year Never (0) to daily or almost daily (4)
have you failed to do what was
normally expected from you because
of drinking?
6. How often during the last year have Never (0) to daily or almost daily (4)
you needed a first drink in the morning
to get yourself going after a heavy
drinking session?
7. How often during the last year have Never (0) to daily or almost daily (4)
you had a feeling of guilt or remorse
after drinking?
8. How often during the last year have Never (0) to daily or almost daily (4)
you been unable to remember what
happened the night before because you
had been drinking?
9. Have you or someone else been No (0) to yes, during the last year (4)
injured as a result of your drinking?
10. Has a relative, friend, doctor or No (0) to yes, during the last year (4)
other health worker been concerned
about your drinking or suggested that
you should cut down?

37. The Nepali version of AUDIT is a reliable and valid screening tool to identify
individuals with alcohol use disorders in the Nepalese population. AUDIT
showed a good capacity to discriminate dependent patients (with AUDIT≥11
for both the gender) and hazardous drinkers (with AUDIT≥5 for males and≥4
for females). For alcohol dependence/abuse the cut off values was≥9 for both
males and females.

38. Treatment Alcohol-Related
Conditions

39. Acute Intoxication
• Assess vital signs
• Manage respiratory depression,
• Cardiac arrhythmia
• Blood pressure instability.
• The possibility of intoxication with other drugs should be considered.
• Aggressive behavior should be handled by offering reassurance but also by
considering the possibility of a show of force with an intervention team.
• If the aggressive behavior continues, relatively low doses of a short-acting
benzodiazepine such as lorazepam (e.G., 1–2 mg PO or IV) may be used
and can be repeated as needed
• An alternative approach is to use an antipsychotic medication (e.G., 0.5–5
mg of haloperidol PO or IM every 4–8 h as needed, or olanzapine 2.5–10
mg IM repeated at 2 and 6 h, if needed).

40. Intervention
There are two main elements to intervention in a person with alcoholism:
MOTIVATIONAL INTERVIEWING
FRAMES:
Feedback to the patient;
Responsibility to be taken by the patient;
Advice, rather than orders, on what needs to be done;
 Menus of options that might be considered;
 Empathy for understanding of the patient's thoughts and feelings;
 Self-efficacy, i.e., offering support for the capacity of the patient to succeed in making
changes.
Brief interventions
•Discussions focus on consequences of high alcohol consumption, suggested
approaches to stopping drinking, and help in recognizing and avoiding situations likely to
lead to heavy drinking.

41. Alcohol Withdrawal
 Tremor of the hands (shakes)
 Agitation and anxiety
 Increase in pulse, respiratory rate, and body temperature
 Insomnia.
• These symptoms usually begin within 5–10 h of decreasing ethanol intake, peak on
day 2 or 3, and improve by day 4 or 5, although mild levels of these problems may
persist for 4–6 months as a protracted abstinence syndrome.

42. • seizure (2–5%)
• delirium tremens (DTs), where the withdrawal
includes delirium (mental confusion, agitation,
and fluctuating levels of consciousness)

43. Treating withdrawal
50–100 mg of
search for evidence of liver failure,
thiamine daily
gastrointestinal bleeding, cardiac
arrhythmia, infection
25–50 mg of chlordiazepoxide or
glucose 10 mg of diazepam given PO
electrolytes every 4–6 h on the first day, with
doses then decreased to zero
over the next 5 days

44. Treatment of the patient with DTs-
 Identify and correct medical problems and to control behavior and prevent
injuries.
 High doses of a benzodiazepine (as much as 800 mg/d of
chlordiazepoxide),
 Antipsychotic medications, such as haloperidol or olanzapine
 Generalized withdrawal seizures rarely require more than giving an
adequate dose of benzodiazepines.
• Phenytoin
• gabapentin
• status epilepticus

45. Rehabilitation
of Alcoholics Cognitive-behavioral
approaches
Counseling
Vocational rehabilitation
Self-help groups such as
alcoholics anonymous
Relapse prevention.

46. Physician’s role
 Identifying the alcoholic
 Diagnosing and treating associated medical or psychiatric
syndromes
 Overseeing detoxification
 Referring the patient to rehabilitation programs,
 Providing counseling
 Medication as needed

47. Medications for Rehabilitation
Drug Dosage MOA BENIFIT REMarks
NALTREXONE 50–150 MG/D BLOCKING OPIOID SHORTEN G ALLELE OF
ORALLY, RECEPTORS, DECREASE SUBSEQUENT THE AII8G
ACTIVITY IN THE DOPAMINE- RELAPSES POLYMORPHISM
RICH VENTRAL TEGMENTAL
REWARD SYSTEM
ACAMPROSAT 2 G/D DIVIDED INHIBITS NMDA RECEPTORS DECREASING
E INTO THREE MILD
ORAL DOSES SYMPTOMS OF
PROTRACTED
WITHDRAWAL.
DISULFIRAM, 250 MG/D. PRODUCES VOMITING AND AVERSION CAN BE
AUTONOMIC NERVOUS THERAPY DANGEROUS
SYSTEM INSTABILITY IN THE WITH HEART
PRESENCE OF ALCOHOL AS DISEASE,
A RESULT OF RAPIDLY STROKE,
RISING BLOOD LEVELS OF DIABETES
THE FIRST METABOLITE OF MELLITUS, OR
ALCOHOL, ACETALDEHYDE HYPERTENSION

48. Refrences
• Dan Longo, Anthony Fauci, Dennis Kasper et al
Harrison's Principles of Internal Medicine 18th Ed. 2011
• Bickram Pradhan et al, The alcohol use disorders
identification test(AUDIT): validation of a Nepali version
for the detection of alcohol use disorders and hazardous
drinking in medical settings.
• Kumar S et. Al, Alcohol use among physicians ina
medical school in Nepal; Kathmandu University Medical
Journal (2006), Vol. 4, No. 4, Issue 16, 460-464

49. • World Health Organization (2008c). Global Survey on
Alcohol and Health. Geneva
(http://www.who.int/substance_abuse/activities/gad/en/,
accessed 28 November 2010)
• Peter D. Friedmann, Alcohol Use in Adults, clinical pr
actice; N Engl J Med 2013;368:365-73.

50. Thank you
•“Alcohol may be man's worst enemy,
but the Bible says love your enemy.”

51. • “Alcohol may be man's worst enemy, but
the Bible says love your enemy.”

52. • "I don't care how liberated this world
becomes, a man will always be judged by
the amount of alcohol he can consume,
and a woman will be impressed, whether
she likes it or not. “
• -Doug Coughlin from Cocktail