This document provides information on alcohol, its effects on the body, alcohol dependence and withdrawal, and treatment approaches. It discusses how alcohol acts in the brain to produce both pleasurable and reinforcing effects. It outlines recommended daily and weekly drinking limits, signs and symptoms of alcohol intoxication at different blood alcohol levels. It also summarizes common presentations to the emergency department related to alcohol, approaches to assessing and managing alcohol withdrawal, risks of Wernicke's encephalopathy from thiamine deficiency, and options for ongoing treatment and support.

1. ALCOHOL – EFFECTS,
DEPENDENCE,
WITHDRAWAL &
TREATMENT
St Vincent’s Hospital D&A Service
Lisa Jayne Ferguson and Jeku Jacob

2. Alcohol
 CNS depressant: acting at several sites in brain
Enhances GABA activity
Stimulates serotonin receptor = pleasure & nausea
Stimulates dopamine and opioid receptors = euphoria
& reinforcement
 Provides kilojoules or energy but NO nutritional value
 Is a toxin to multiple organs

3. Alcohol
1 standard drink (10 gm) raises the
BAL by approximately 0.02
The body/liver processes 1 standard
drink (10 gm) per hour
BAL continues to rise for 30 – 90
minutes after the last drink

4. The National Health & Medical Research Council 2009
Recommended maximum: (1/100 lifetime chance of death)
 Women: 2 standard drinks/day
 Men: 2 standard drinks/day (was 4)
Risky: ie increasing life time risk of death
 Women: 3 standard drinks/day
 Men: 5 standard drinks/day
Known to cause harm: - chronic organ damage
 Women: Over 4 standard drinks/day
 Men: Over 6 standard drinks/day
 Pregnant women recommends 0 drinks – data still sparse
 Health benefits of Alcohol greatly exaggerated

5. Alcohol Dependence
 More common than dependence on all other drugs
combined in Australia
 About 5% of Australians are dependent
 17 times as common as opioid dependence
 10% receive some form of treatment
 Only 1% are prescribed anti-craving drugs ...this is
compared to -30% opioid dependent people in treatment
 Alcohol contributes to over 3,000 deaths per year and
50,000 hospitalisations

6. Alcohol Intoxication
0.01-0.02
Sense of well being
0.02-0.05
Slightly dizzy, talkative, over-confident, euphoria,
clumsy
0.06-0.1
Decrease inhibitions & motor co-ordination. Increase
pulse, ataxia, talkative
0.2-0.3
Poor judgement, nausea, vomiting
0.3-0.4
Blackout, memory loss, emotionally labile
0.4+
Stupor, breathing reflex threatened, deep anaesthesia,
death (in non tolerant people)

7. High Alcohol Consumption – Long Term
Effects
 GIT/Hepatic




Alcoholic Hepatitis
Cirrhosis
Pancreatitis
Colitis
 Nervous System
 Endocrine
 Hypgoglycemia (don’t give
thiamine until you replace sugar)
 Hypogonadism
 Oncology
 Increased risk of mouth, colon,
breast and larynx
 Wernicke/Korsakoff’s
 Alcoholic Dementia
 Myopathy
 Obstetric
 Neuropathy
 Hematologic
 Cardiac
 AF
 Hypertension
 Cardiomyopathy
 Foetal Alcohol Syndrom
 Bone marrow suppression leads
to macrocytic anemia
 Cirrhosis can lead to
thrombocytopenia

8. Alcohol Related
Presentations to ED

9. Common Presentations
 Pt can usually come in complaining of withdrawal symptoms.
 Hallucinations
 Tremors
 Sweats
 Anxiety
 Perceptual disturbances
 Seizures
 Hemetemesis
 Abdominal Pain
 Falls
 Palpitations
 Productive Cough
 Jaundice
 Feeling unwell
 Intoxication
 Trauma/ Violence

10. History taking
 Please take a good history
 Try to quantify alcohol use to grams/SD
 How often they drink (try to take a day history)
 Last drink?
 Age of starting drinking
 Reasons why drinking was exacerbated
 ?Depression/Suicidality
 Social Situation
 Any other substances of misuse
 Please exclude other causes of presentation

11. Physical Findings
 Signs of Chronic Liver Disease
 In withdrawal
Anxious
Sweaty
Tachycardic and Hypertensive
Tremulous
 Wernicke’s: confused, ataxic and opthalmoplegic
 Malnourished
 Encephalopathic if CLD

12. Investigations









UDS
BAC
BSL
FBC – may show macrocytic Anemia
UEC, LFTS, CMP
B12 + folate – usually deficient
INR - caogulopathy
CT brain if history of fall/seizures or ataxic
U/S abdomen if you suspect CLD

13. Management
Hydrate
Thiamine (BEFORE GLUCOSE) – youll
never go wrong with giving more
300 mg tds iv please to start on all intoxicated
pts
500 mg tds iv if you suspect wernicke’s
Glucose in thiamine deficiency precipitates
wernicke’s
Replace Sugar please if glycopenic
Replace Electrolytes

14. Alcohol Withdrawal
Is a syndrome of central nervous system hyperactivity
Onset
 Usually between 6-24 hours after last regular dose of
alcohol (symptoms occur as blood alcohol concentration
decreases)
Duration
 Between 2-7 days (most commonly 4-5 days)
 Residual symptoms will last longer when brain injury is
involved

15. Rationale
 Withdrawal symptoms can range from mildly
uncomfortable to life threatening
 Symptoms can be prevented or alleviated
 Early intervention can reduce or prevent progression to
severe withdrawal, injury, dehydration or seizures

17. Severe Alcohol Withdrawal
Symptoms
CAN BE FATAL (RARELY)
Seizures - 6-48 hours
Mod-Severe Hypertension - 6-48 hours+
(Diastolic above 110)
Disorientation - 48 hrs+
Confusion - 48 hrs+
Hallucinations - 48 hrs+
Delirium Tremens- 48 hrs+

18. Alcohol Withdrawal Scales
 The most systematic & useful way to measure
the severity of withdrawal is to use a
withdrawal scale
 These provide a baseline against which changes
in withdrawal severity may be measured over
time
 Research shows that the use of scales minimises
both under-dosing & overdosing with
benzodiazepines for alcohol withdrawal
syndromes

19. AWS
 Please do not start AWS prematurely
 Calculate when BAC will return to normal, then start
 (Pt’s may go into withdrawal prior to this – clinical
perogative necessary)
 AWS not diagnostic...make diagnosis of withdrawal first
before instituting
 5 – 10 mg every 4 hours with a cap of 80 mg in the first
24 hours
 Can get 120 mg in first 24 hours if appropriate

20. Perceptual disturbances/
Hallucinations in withdrawal
Curtains/floor/furniture moving
‘Insects over skin’
Hallucinations rarer and signify severity of
withdrawal
colour changes
Animal forms
Scary
These require antipsychotics
Olanzapine

21. Special Considerations
Use Oxazepam (7.5-45mg) if:
Cirrhosis
Be careful with doses of BZD
Elderly
Head injury
Stay away from BZD if delerious, use
antipsychotics instead
Difficulty in encepholapathy  use
lactulose!

22. Gorman House
 Pts in ED who don’t require admission can be
rehydrated, given thiamine and discharged
 Gorman House is appropriate for detoxification
 Gorman House – 5/7 program
 Pts need to be discharged on weaning diazepam
 Day 1 – 10mg qid
 Day 2 – 10 mg tds
 Day 3 – 10 mg bd
 Day 4 – 10 mg daily

23. Wernicke-Korsakoff Syndrome
 Form of brain injury resulting from thiamine
deficiency
 If not treated early it can lead to permanent brain
damage & memory loss
 Signs & symptoms of Wernicke’s encephalopathy
(usually the first stage of the syndrome) =
1. Ophthalmoplegia (reduced eye movements) or
Nystagmus (dancing eyes)
2. Ataxia
3. Confusion

24. Wernicke-Korsakoff Syndrome
 This condition is reversible if recognised and treated
with parenteral vitamin B1
 Parenteral thiamine should be administered before
any form of glucose
 Glucose in the presence of thiamine deficiency risks
precipitating Wernicke’s encephalopathy
 Korsakoff’s by itself : confabulation, amnesia and apathy
 (ask: ‘do you remember me?’ Or ‘where did we meet
before’

25. Wernicke-Korsakoff Syndrome
 NB: Studies have shown that the absorption of PO
thiamine in alcohol dependent patients is minimal to
none!!!
 Example of dosing regime:
 Thiamine 300mg tds IVI / IMI for 3/7’s , then PO
 If WE established: Thiamine dose should be increased

26. Potential Problems
 High doses of Diazepam should not be used to treat
alcohol related delirium
 Diazepam can precipitate and cause delirium
 Olanzapine/Haloperidol can lower seizure threshold
 AWS should only be used for Alcohol, not opioid or
benzodiazepine withdrawal

27. Treatment Options for Patients
 Follow up with outpatient services / Tx –
- 1:1 counselling (public & private),
- Groups (SMART Recovery, AA’s)
- Residential Rehab,
- Pharmacotherapy‘s
* Impaired Cognition (Moderate-Severe)
1. Cognistat /Neuropsych Assessment
2. Guardianship /Inebriates Act
3. Placement?????

28. Take Home Messages
Take a good alcohol history
Don’t start the AWS too early
Please replace thiamine iv before glucose
(at least one dose)
 AWS not diagnostic – pt not improving,
consider alternative diagnosis

29. SVH A&D Service
THANK YOU 