Alcohol Flashcards
What is the ICD-10 criteria for addiction?
3 of the following symptoms, present together at some time during the previous year or constantly for 1 month:
- Strong desire for substance
- Difficulties in controlling substance taking behaviour in terms of its onset, termination or levels of use
- Evidence of tolerance, have to take higher levels for same effect
- Withdrawal symptoms when stopping usage
- Salience over other things in their life
- Continuous use even though they know it’s harmful
What are alcohol withdrawal symptoms?
- Symptoms start at 6-12hr: tremor, sweating, tachycardia, anxiety, tachypnoea
- Peak incidence of seizures at 36hrs
- Peak incidence of delirium tremens at 48-72hrs
What are the symptoms of delirium tremens?
- Autonomic hyperactivity
- Tachycardia
- Fever
- Insomnia
- Anxiety
- Hypertension
- Perceptual distorsions
- Visual or tactile and auditory hallucinations (formication)
- Fluctuating motor activity (hyperactivity to lethargy)
- Coarse tremor
- Delusions
What is the pharmacological management of alcohol withdrawal?
- 1st line: long acting benzodiazepines e.g. chlordiazepoxide (Librium) or diazepam
- Lorazepam may be preferred in hepatic failure
- Carbamazepine also effective in treatment of alcohol withdrawal
- Rehydration with IV fluids and pabrinex to reduce risk of Wernicke’s encephalopathy
- Always include thiamine Vit B1
What are the symptoms of Wernicke’s encephalopathy?
- Clinical triad: opthalmoplegia (weakness of eye muscles) with nystagmus, ataxia and confusion
- Peripheral sensory neuropathy, altered GCS
Life threatening illness due to thiamine deficiency
What are the investigations and treatment for Wernicke’s encephalopathy?
- Investigations: decreased red cell transketolase (detects thiamine deficiency), MRI
- Treatment: high dose thiamine
What is Korsakoff’s syndrome?
- Wernicke’s, if untreated, can develop into Korsikoff’s syndrome
- Neuropsychiatric disorder associated with memory disturbances in which there are significant deficits in anterograde and retrograde memory
- Immediate memory is maintained but short term memory is diminished with intact sensorium
What are features of Korsikoff’s syndrome?
- Associated with patients fabricating stories in the setting of clear consciousness. Confabulations can be spontaneous or provoked (former in acute Wernicke’s state and latter in chronic Korsikoff’s).
- Anterograde/retrograde amnesia
- Apathy
- Lack of insight
What are the current UK guidelines for alcohol consumption?
- 14 units/wk
- 6 pints of 4% beer, 7 175ml glass of wine a week
- Units = strength (ABV) x volume (ml) / 1000
What are the mental and behavioural disorders due to psychoactive substance use?
- Acute intoxication
- Dependence syndrome
- Harmful use
- Withdrawal state
- Pyschiatric disorder
- Amnesic syndrome
What is the ICD-10 diagnosis of substance dependence?
- Physical:
- Experiencing withdrawal symptoms if not used
- Use of substance to relieve withdrawal symptoms - Psychological:
- Intense desire to use (craving)
- Difficulty in controlling the onset, termination and amount used
- Tolerance (need to escalate dose over time to achieve same effect) - Social
- Salience (neglecting alternate forms of leisure or pleasure in life)
- The narrowing personal repertoire of substance use
At least 3 in past 12 months.
What are the physical health risks of using alcohol?
- Cardiovascular: Cardiomyopathies, Arrhythmias (during withdrawal), high BP, increased risk of stroke
- GI: cancer of mouth, oesophagus, liver, throat, larynx; Oesophagitis, gastritis; liver cirrhosis
- Females: reduced fertility, breast cancer, harm to unborn babies
- Psychological: depression and anxiety
What are the psychological health risks of alcohol use?
- Disinhibition (linked to intoxication and binge drinking)
- Depression (direct depressive effect plus reduces effectiveness of antidepressants)
- Anxiety (may be linked to low level withdrawal)
- Memory impairment (Korsikoff’s, alcohol related brain damage, dementia)
- Self harm/suicide (often linked to social losses and isolation)
- Psychosis: (rare form of chronic auditory hallucinations, repeat experience of DTs)
What are short term the social consequences of alcohol use?
- Accidents or injuries
- Aggression to others
- Victim of violence
- Unprotected sex
- Loss of possessions
- Alcohol possessions
What are the long term social consequences of alcohol use?
- Unemployment
- Domestic violence
- Divorce
- Homelessness
- Financial impact
- Driving convictions
What are the screening tools for alcohol dependence and harmful drinking?
- CAGE questionnaire
- AUDIT (indicates level of dependence)
- SADQ: mild - =15, moderate - 15-30, severe >/=31
- Leeds Dependence Questionnaire: low dependence <10, medium 10-22 + high >22
- FAST used by emergency department to assess alcohol state
How do you start an alcohol history?
Open questions:
- Could you tell me about your usual drinking habits?
- Could you take me through a typical day of drinking for you?
- When did you first start drinking? What did you drink then?
- How have things changed since you first started drinking?
Move to specifics re quantity and circumstances of current drinking
- Time of first drink, any days off, alone or socially, efforts to control
What questions in the history do you want to ask about alcohol dependence?
- Do you find it difficult at times to control the amount you drink?
- Do you find you need to drink much more to achieve similar effects as in the past?
- How do you feel before the first drink of the day?
- Explore physical withdrawal symptoms
- Would you say that alcohol has taken priority for you? OR do you prefer to have a drink than do other things?
- Do you start drinking first thing in the morning?
- Have you ever tried to stop drinking? What happened then?
What are the stages of the CIWA score?
- <9 absent - mild withdrawal, typically no medications
- 9-19 moderate withdraw, medicated to treat
- > 20 severe withdrawal, inpatient withdrawal
What is involved in the alcohol withdrawal regimes?
- Can be done in community from alcohol services
- Dangerous for patients to suddenly stop at home
- May need to wait for detox to be organised - advice to continue drinking reduced amount rather than stop suddenly whilst waiting
- Likely to need residential or hospital detox if: <30 units/day, hx of epilepsy or previous DTs, comorbid substance misuse/physical or mental health
What medications are used to help alcohol cravings?
- Acamprosate
- Naltrexone
What are the psychological and social approaches for treating alcohol disorders?
- Psychological: motivational interviewing, CBT, group programme
- Social: 12 steps programme, AA, rehab programme
