addiction Flashcards
What is the epidemiology of alcohol addiction?
- UK prevalence = 7% males, 2% females
- 25% of emergency admissions are alcohol related
- Females have a stronger genetic preposition so are more likely to suffer from the physical complications
- Prevalence greater in deprived areas
- Prevalence lower in east Asians - Asian flush, particular isoenzyme of alcohol dehydrogenase leads to accumulation of acetaldehyde
What are the genetic risk factors for alcohol addiction?
7x increased risk if first degree relative has alcohol misuse.
o The genetic influence is thought to exert itself through heritable personality traits or through single genes that modulate the body’s response to alcohol.
What are the neurochemical risk factors for alcohol addiction?
Alcohol increases GABA, dopamine and serotonin
o Euphoric effects
In alcohol dependence there is a compensatory upregulation of glutamate to compensate for the (GABA- ergic) CNS depressant effects of alcohol.
o Suddenly withdrawing alcohol therefore leads to symptoms of CNS hyperexcitability.
What are the psychological theories behind alcohol addiction?
There is no such thing as an ‘alcoholic personality’, although anxiety disorders, borderline personality disorder, antisocial personality disorder, and a history of childhood conduct disorder are particularly associated with alcohol misuse.
According to cognitive-behavioural theories, alcohol dependence may result from positive reinforcement (seeking out the pleasant effects of alcohol) and negative reinforcement (avoiding the negative effects of alcohol withdrawal), from a conditioned response to one or more circumstances (e.g. a pub or nightclub), or from modelling the drinking behaviour of relatives, peers, and ‘celebrities’.
According to psychodynamic theories, alcohol dependence may result from maternal deprivation, childhood sexual abuse, or unconscious gains resulting from intoxication and personal damage caused.
What are the social risk factors for alcohol addiction?
Life events: life events such as separation, bereavement, or loss of employment
Occupation: certain occupational groups are at a higher risk of alcohol dependence
o E.g. publicans and bar staff, salesmen, entertainers, journalists, and doctors.
o Generally speaking, alcohol dependence is more prevalent in the unskilled manual social class and in the unemployed.
Population levels of alcohol consumption:
o can be controlled through three factors: price, availability, and social attitudes to alcohol.
What comorbidities are common in alcohol addiction?
often occurs secondary to other psychiatric or medical disorders
What are the core features of alcohol dependence?
- Compulsion to drink
- Primacy of drinking over other activities
- Stereotyped pattern of drinking
(e. g. narrowing of repertoire) - Increased tolerance to alcohol
- Repeated withdrawal symptoms
- Relief drinking to avoid withdrawal symptoms
- Reinstatement after abstinence
DIAGNOSIS = 3/7 FEATURES OCCURRING ANYTIME DURING 12-MONTH PERIOD
What are alcohol withdrawal symptoms and when do they occur?
• Usually occur after several years of heavy drinking
• Range from mild anxiety and sleep disturbance to life threatening delirium tremens
• Occurs first thing in morning
• Common symptoms
o Agitation, tremor ‘the shakes’, nausea and retching
What is the acute management of alcohol withdrawal?
• Prevention and treatment involves:
o benzodiazepines (lorazepam)
o correction of fluid and electrolyte imbalances
o treatment of concurrent infections
o parenteral multivitamin injection (PABRINEX)
THIAMINE – Pabrinex (water-soluble vitamins C (ascorbic acid), B1
(thiamine), B2 (riboflavin), B3 (nicotinamide) and B6 (pyridoxine).
• Prevent Wernicke’s encephalopathy
• Delerium Tremens often complicates other medical emergencies such as infection and injury, and
fever/signs of shock are poor prognostic signs.
• It’s untreated mortality rate is ~10%.
What is delerium tremens, when does it occur and what are the characteristics?
- medical emergency that occurs in about 5% of alcohol dependent people at 1-3 days after stopping alcohol.
o It is relatively common - especially in hospital inpatients. - It is a delirious disorder characterised by:
o Clouding of consciousness
o Disorientation in time and place
o Impairment of recent memory
o Fear, agitation and restlessness.
o Vivid hallucinations (most commonly visual) and delusions (most commonly paranoid).
o Insomnia
o Autonomic disturbances (tachycardia, hypertension, hyperthermia, sweating, dilated pupils).
o Coarse tremor
o N&V
o Dehydration and electrolyte disturbances
o Seizures.
What are the differentials for delerium tremens?
Hypoglycaemia, drug overdose and other causes of delirium (e.g. UTI).
DTs should be differentiated from alcohol hallucinations and Wernicke’s encephalopathy.
What is alcohol hallucinosis?
Auditory hallucinations – first fragmentary sounds then derogatory voices, usually 3rd person.
Can persist several months after abstinence and in some cases, leads to secondary delusions.
Notoriously unresponsive to antipsychotics.
What is wernickes encephalopathy and what is it caused by?
• Wernicke’s encephalopathy is a medical emergency.
• Results from thiamine (vit B1) deficiency
o Most commonly due to alcohol dependence but can be starvation, malabsorption, hyperemesis and CO poisoning
What are the symptoms of wernickes encephalopathy?
• Classic triad:
o Confusion
o Ataxia
o Ocular palsy
• Acute onset, other Sx include:
o impaired consciousness and confusion, episodic memory impairment, ataxia, nystagmus, abducens and conjugate gaze palsies, pupillary abnormalities, and peripheral neuropathy
What is the treatment for wernickes encephalopathy?
- Treatment involves parenteral thiamine (pabrinex), but only 20% of suffers recover, and 10% die from haemorrhages in the brainstem and hypothalamus.
- The remainder go on to develop Korsakov’s syndrome (amnestic syndrome)
What is korsakoffs syndrome and what symptoms do you get?
• An irreversible amnestic syndrome characterised by:
o Prominent impairment of recent memory
o A lesser extent remote memory
- Resulting from neuronal loss, gliosis, hemorrhage in the mamilliray bodies and damage to the dorsomedial nucelus of the thalamus
- Confabulation - falsification of memore in clear consciousness may be a marked feature but immediate recall, perception and other cognitive functions are usually intact
What is the cage questionnaire?
Rapid screening questionnaires such as the CAGE questionnaire may be useful in this context,
although they are not as sensitive as a comprehensive alcohol risk assessment.
C Have you ever felt you should Cut down on your drinking?
A Have people Annoyed you by criticising your drinking?
G Have you ever felt bad or Guilty about drinking?
E Have you ever taken a drink first thing in the morning (Eye opener)?
Two or more positive replies are said to identify alcohol misuse.
What should you do if patient drinking habits are difficult to assess?
take an informant history or ask the patient to keep an alcohol diary.
When might blood tests be useful in alcohol intake and which ones would you do?
helpful in augmenting the findings of screening questionnaires such as the CAGE questionnaire, and in monitoring progress.
• Blood tests may be useful in uncovering misuse and monitoring progress:
o GGT is raised in about 80% of heavy drinkers
o ALP in about 60%
o MCV in about 50%
Of the three tests, MCV has the highest specificity for alcohol misuse but, due to the long half-life of red blood cells (120 days), may remain elevated for a long time after the patient has stopped drinking.
What is the very early intervention for alcohol misuse?
delivered in primary care and involves simple advice and support, and appraisal of current medical, psychological, and social problems.
o MOTIVATIONAL INTERVIEWING
help to recognize problem; help to resolve ambivalence and encourage positive change and belief in ability to change; adopting a persuasive and supportive position rather than being argumentative
o For homeless patients consider offering residential rehabilitation for a maximum of 3 months. Then help the service user to find stable accommodation before discharge
What is the treatment for someone who is dependent on alcohol?
DETOXIFICATION is required.
o Over 15 units/day or >20 on AUDIT
o This involves a reducing course of a benzodiazepine in lieu of alcohol
e.g. chlordiazepoxide 20 mg QDS reducing daily over 5–7 days and supplemented by thiamine 200 mg OD (often in the form of a multivitamin preparation).
• The starting dose of chlordiazepoxide is estimated by units of alcohol intake per day (or SADQ score) e.g. 30 U/day 30 mg QDS
Lorazepam preferred over chlordiazepoxide in patients with hepatic failure to avoid the risk of increased sedation
When should hospitalisation be considered in detox?
o Detoxification can usually be carried out in the community either by the GP practice or the local substance misuse service, but hospital admission should be considered if the patient has a comorbid medical or psychiatric disorder (including drug misuse), a history of convulsions or delirium tremens, or a lack of social support.
How can you enhance abstention from alcohol in patients?
maintenance treatments such as the opiate antagonist naltrexone (not currently licensed in the UK), acamprosate (Campral), and disulfiram (Antabuse).
Acamprosate is an ‘anticraving’ drug that enhances GABA neurotransmission and therefore mimics the CNS depressant effects of alcohol.
Disulfiram on the other hand is an alcohol-sensitising deterrent drug that blocks the oxidation of alcohol by irreversibly inhibiting the enzyme aldehyde dehydrogenase, leading to an accumulation of acetaldehyde and associated symptoms of flushing, palpitations, headache, nausea, and a choking sensation (it can be thought of as a chemical form of aversion therapy). For this reason, it should not be started until the breath alcohol has returned to zero. It is contra- indicated in hypertension, coronary artery disease, and cardiac failure as it can cause cardiac arrhythmias; other side-effects include sedation, constipation, and halitosis (bad breath).
• Maintenance treatments require close supervision, often by a nominated ‘supervisor’ such as the patient’s spouse, and are not a substitute to psychosocial interventions.
What psychosocial interventions should be used for alcohol abusers?
community alcohol services, Alcoholics Anonymous, supportive psychotherapy (including supportive psychotherapy for carers), cognitive-behavioural therapy, and marital and family therapy.
• Social skills training is an effective component of substance misuse treatment programmes
o aims to impart the skills needed to function more effectively in social situations, and involves a variety of interventions such as role playing in groups (e.g. declining the offer of an alcoholic drink, or going to a bar and ordering a non-alcoholic drink), assertiveness training, and problem solving skills.
What is an opioid?
any agent that binds to opioid receptors, including endogenous opioid peptides, opium alkaloids such as morphine and codeine, semi-synthetic opioids such as heroin and oxycodone, and fully synthetic opioids such as pethidine and methadone.
What is an opiate?
natural opium alkaloids and the semi-synthetic opioids derived from them.
