ALCOHOL Flashcards
1
Q
What is acute intoxication?
A
a transient condition that follows the administration of alcohol or a psychoactive substance and results in disturbances in the level of consciousness, cognition, perception, judgment, affect or behavior, or other psychophysiological functions and responses.
2
Q
What is acute intoxication?
A
A pattern of reversible physical and mental abnormalities caused by direct effects of the substance
3
Q
What are the behavioural effects of alcohol when blood alcohol concentration is 20-99mg/dL (0.02-0.099%)?
A
Impaired cognition and euphoria
4
Q
What are the behavioural effects of alcohol when blood alcohol concentration is 100-199mg/dL (0.10-0.199%)?
A
Ataxia, poor judgement, labile mood
5
Q
What are the behavioural effects of alcohol when blood alcohol concentration is 200-299mg/dL (0.20-0.299%)?
A
Marked ataxia, slurred speech, poor judgement, labile mood, nausea and vomiting
6
Q
What are the behavioural effects of alcohol when blood alcohol concentration is 300-399mg/dL (0.30-0.39%)?
A
Stage 1 anaesthesia, memory lapse, labile mood
7
Q
What are the behavioural effects of alcohol when blood alcohol concentration is 400+mg/dL (?0.40%)?
A
Respiratory failure, coma, death
8
Q
What is binge drinking?
A
Drinking twice the daily limit in a single session. >6 units in women and >8 units in men
9
Q
What is considered harmful use of alcohol?
A
a pattern of alcohol consumption causing health problems, physical or mental, directly related to alcohol.
10
Q
What proportion of cases of alcohol misuse will lead to chronic alcohol dependance?
A
25%
11
Q
What is alcohol dependance?
A
craving, tolerance, a preoccupation with alcohol and continued drinking in spite of harmful consequences
12
Q
What are the diagnostic guidelines for dependance?
A
3 or more of the following present together at some time during the previous year:
- a strong desire to take the substance
- difficulties in controlling substance-taking behaviour (onset, termination, levels of use)
- a physiological withdrawal state when substance use has ceased/reduced or use of the same substance with the intent of relieving or avoiding withdrawal symptoms
- evidence of tolerance (increased doses required to achieve effects originally produces by lower doses)
- progressive negelect of alternative pleasures and interests because of psychoactive substance use
- persisting with substance use despite clear evidence of overtly harmful consequence
- narrowing of the personal repertoire of patterns of drinking
13
Q
What is tolerance?
A
a need for markedly increased amounts of a substance to achieve intoxication or desired effect. Or marked diminished affect with continued use of same amount of a substance
14
Q
For those with alcohol problems, Whats the increased risk of dying compared with the general population of the same age and sex?
A
2-3 times higher
15
Q
Whats the genetic component to alcohol misuse?
A
There is a 7 fold increased risk of alcoholism among 1st degree relatives of alcoholics
Male monozygotic twins have 70% risk of alcoholism if their twin has it
P300 predicts alcohol abuse
Adoption studies: Sons of alcoholics are 4x more likely to be alcoholic than sons of non-alcoholics, regardless of the drinking patterns of adoptive parents
16
Q
What may contribute to risk patterns of alcoholism among oriental populations?
A
Variations in allele compositions for alcohol dehydrogenase and aldehyde dehydrogenase
17
Q
Outline the biochemical effects of alcoholism?
A
Chronic alcohol consumption enhances GABA mediated inhibition in the CNS and inhibits NMDA-type glutamate receptors = sedation and amnesia
Alcohol stimulates dopamine release in nucleus accumbens and potentiates effects of serotonin = euphoria
18
Q
What are some psychodynamic factors for alcoholism aetiology?
A
Maternal overprotection
Childhood sexual abuse
19
Q
What are the behavioural factors for alcoholism aetiology?
A
Modelling from parents, relatives, peers etc (i.e. social norm)
Euphoriant effect is a positive reinforcer
In times of stress and negative life events people turn to alcohol
20
Q
What are the 2 personalities of alcoholics?
A
Type 1 - more dependant, starts later in life, anxious, rigid, guilty, mother or father as alcoholic
Type 2 - early onset, socially detached, distractingly, confident, aggressive, behaviour is linked to a similar pattern in the biological father
21
Q
Which groups of people are alcohol disorders more common in?
A
Homeless
Lower socioeconomic groups
Adverse childhood experiences
Parents had alcohol or substance abuse
Psychiatric illness
Those living in urban areas
Divorced/separated
Those who sell alcohol
Entertainers, doctors, journalists,
In places where excess consumption is societal norm
22
Q
What systems can alcohol have consequences on?
A
Hepatic
GI
Haematological
Neurological
Cardiovascular
Pregnancy
Social
23
Q
What are alcohol related consequences concerning the liver?
A
Fatty liver - 90% of drinkers
Alcoholic hepatitis
Cirrhosis - 10% of chronic alcoholics
Carcinomas - 15% of those with cirrhosis
Portal hypertension
24
Q
Having 80g of alcohol a day for >10 years increases the risk of liver disease by how much?
A
Nearly 100%
25
Which antigen makes a person more vulnerable to cirrhosis and which has a protective affect?
HLA-B8 vulnerable
HLA-A28 protective
26
What are alcohol related consequences concerning the GI system,?
Barretts oesophagitis
Oesophageal varices
Mallory-Weiss tears
Peptic ulceration and gastritis
Cancers: oropharnyx, larynx, oedeophagus, liver
Diabetes mellitus
27
What are alcohol related consequences concerning the haematological system?
Macrocytosis
Thrombocytopenia and anaemia may also occur
Neutropenia
Zieve’s syndrome
28
What is Zieves syndrome?
A rare form of alcoholic haemolysis secondary to alcoholic induced liver injury
It’s a triad of jaundice, haemolytic anaemia and hyperlipidaemia
29
What are alcohol related consequences concerning the neurological system?
Delirium tremens
Withdrawal seizures
Cerebella degeneration
Haemorrhagic stroke
Peripheral and optic neuropathy
Wernickes encephalopathy and Korsakoff’s syndrome
Alcohol dementia
30
What is delirium tremens
The most serious withdrawal state that occurs 2-3 days after withdrawal.
Pt have rapid onset confusion and will be disorientated and agitated. They have tremor and visual hallucinations
They would be sweating, tachycardia, tachypnoeic and pyrexia
Complications include dehydration, infection, hepatic disease and wernicke-korsakoff syndrome
31
What is alcoholic hallucinosis?
When auditory hallucinations occur alone in clear consciousness. It usually clears in a few days but may be followed by secondary delusional misinterpretation
sometimes may progress to a chronic form mimicking schizophrenia
32
What causes wernicke-korsakoff syndrome?
Lack of thiamine
33
What are alcohol related consequences concerning the cardiovascular system?
Hypertension
Arrhythmias
IHD
Alcoholic cardiomyopathy
34
What are alcohol related consequences concerning the pregnancy?
Alcohol in pregnancy is associated with increased risk of:
- stillbirth
- neonatal mortality
- low birth weight
- later difficulties with attention e.g. ADHD
- distractability
- foetal alcohol syndrome
35
What are signs of foetal alcohol syndrome?
Microcephaly, mental retardation, low birth weight, cleft palate, ptosis, scoliosis, abnormal dermatoglyphics, congenital heart disease, congenital renal disease
36
How much do you have to drink to cause foetal alcohol syndrome?
4-5 units a day
37
What are some social-related consequences caused by alcohol?
Increased rates of abuse of partner, divorce, child abuse, later alcoholism in children, 2.5 times as many days off work, decreased productivity, sexual difficulties, financial diffiuclties, crime, homelessness
38
What proportion of alcoholics meet criteria for another psychiatric disorder?
47%
39
What proportion of alcoholics have depressive symptoms?
70-90%
40
What proportion of completed suicides is associated with heavy drinking?
25%
Alcoholics have >7 times the expected suicide rate
41
What are some psychiatric consequences of alcoholism?
Depression
Suicides
Anxiety
Schizophrenia
Morbid jealousy
Delirium tremens
42
When does risk of delirium tremens increase?
4 to 5 pints of wine, 7 to 8 pints of beer, or 1 pint of hard liquor every day for several months. Similarly, delirium tremens can also affect people who have used alcohol for more than 10 years.
43
Whats the classic triad for delirium tremens?
Clouding of consciousness and confusion
Vivid hallucinations that are visual or tactile
Marked tremor
44
Which function areas of the brain are affected (in order) when we drink alcohol?
Prefrontal - ntellect - loss of reasoning and moral codes
Amygdala - Emotions - higher emotions
Cerebellum - Motor function - impairment of coordination, balance and judgement
Hippocampus - loss of memories
Hypothalamus and pituitary - Involuntary systems - nausea and vomiting as food fails to be properly digested, libido increases but ability to perform the sexual act is lose
Medulla oblongata - Vital systems - unconsciousness, vital organs start to shut down and can cause death
45
How should you assess someone for alcohol misuse?
Take a longitudinal (life time) and cross sectional history (current) about alcohol use
Investigations including blood test to see raised GGT, MCV and low ALT
Assess for evidence of dependance using ICD10 criteria
Ask about physical, mental and social complications
Risk assess
46
What does an AST:ALT >1 suggest?
Alcoholic liver disease
47
What 2 questionnaires are used for alcohol use?
CAGE and AUDIT-C
48
What is the CAGE questionnaire?
Have you ever felt you should Cut down on drinking?
Have people Annoyed you by criticising your drinking?
Have you ever felt Guilty about your drinking?
Have you ever had a drink first thing in the morning to steady nerves or rid of a hangover (Eye opener)?
A total score of 2 or more is considered clinically significant
49
Outline the AUDIT-C questionnaire?
How often do you have a drink containing alcohol?
How many units of alcohol do you drink on a typical day when you are drinking?
How often have you had 6/8 or more units (female/male) on a single occasion in the last year?
Scoring of 5+ on indictates increasing or higher risk drinking
50
What are alcohol withdrawal symptoms?
Hand tremors
Sweating
Nausea
Visual hallucinations
Seizures
Depression
Anxiety
Irritability
Insomnia
Restlessness
51
What is ‘kindling’ when referring to alcohol withdrawal?
The severity of withdrawal symptoms will increase after repeated withdrawal episodes
Important to treat everyone aggressively regardless of their withdrawal severity to prevent the increase in severity of subsequent withdrawal episodes
52
When will symptoms of alcohol withdrawal start and peak? How long can they last?
Commence within 12 hours
Peaks 48-72 hours
Sympotms may persist for several days or even weeks
53
How much pure alcohol is 1 unit of alcohol equal to?
0.01L or 10ml
54
How do you calculate units of alcohol?
% x volume in litres
55
Which alcohol screening tool has the highest sensitivity of 20-90%?
Raised GGT
56
Which alcohol screening tool has the highest specificity of 85-95%?
Raised MCV
57
What 4 things should you consider when thinking about treatment for alcohol use?
Substitution - no clear evidence base though
Detoxification and withdrawal
Preventing complications
Relapse prevention
58
Whats the management for detoxification from alcohol?
Benzodiazepine treatment or carbamazepine
59
How should you prevent complications when helping someone with alcohol withdrawal?
Give vitamin B1 parenterally as alcoholics tend to be malnourished and intoxicated alcoholics absorbed up to 4/5th less thiamine if taken orally
60
Other than pharmacotherapy, what can be offered to help with treating alcohol misuse?
Group therapy
Individual counselling
Inpatient detoxification
Alcoholics Anonymous
However none have strong proven efficacy
61
What 3 drugs can be used to prevent relapse in alcohol detoxification?
Naltrexone
Acamprosate
Disulphiram
62
What is naltrexone and how does it work?
An opioid antagonist used to reduce the number of relapses and reduce alcohol consumption
Reduces the reinforcing actions of alcohol
Once they have stopped drinking, it stops them relapsing
63
What is acamprosate and how dos it work?
A drug used to prevent relapse by reducing the reinforcement caused by endogenous opioids
It reduces endogenous excitatory neurotransmitters and enhances GABA transmission
64
What is disulphiram and how does it work?
It inhibits acetaldehyde dehydrogenase so when the person drinks alcohol it causes facial flushing, headaches, palpitations, n+v, increased temperature pulse and decrease bp. Risk of coma and death
It’s meant to deter you from drinking alcohol
65
When does NICE recommend trying disulphiram?
Only after a trial of naltrexone or acamprosate
66
What are the risks of disulphiram?
Disulfiram can react with alcohol. Some foods, perfumes, aerosol sprays, and other everyday substances may contain alcohol and so can react with disulfiram.
avoid in Acute porphyrias; diabetes mellitus; epilepsy; respiratory disease
Contraindicated in cardiac failure; coronary artery disease; history of cerebrovascular accident; hypertension; psychosis; severe personality disorder; suicide risk
67
Whats the treatment for harmful drinking and mild alcohol dependance?
Psychological therapy
If this doesnt work you may be offered acamprosate or naltrexone at the same time
68
Whats the treatment for moderate and severe alcohol dependance?
Planned withdrawal from alcohol “detox” - i.e. with medical health
Psychological treatment
Medication - benzodiazepines (unlise hepatic impairment)
69
Who should be offered planned withdrawal from alcohol in hopsital or in a residential rehabilitation unit?
you drink more than 30 units of alcohol a day
you have epilepsy or have had delirium tremens during a previous planned withdrawal from alcohol
you are dependent on benzodiazepines and need to withdraw from them as well as alcohol
you regularly drink between 15 and 30 units of alcohol a day and also have a severe physical or mental illness or a severe learning disability.
70
What is motivational interviewing?
A directive, patient-centred counselling style that aims to help patients explore and resolve their ambivalence about behaviour change.
71
What are the 4 central principles of motivational interviewing?
1. Express empathy using reflective listening to convey understanding of the pt point of view
2. Develop discrepancy between pt most deeply held values and current behaviour
3. Sidestep resistance by responding with empathy and understanding
4. Support self-efficacy by building the pt confidence that change is possible
72
Outline the cycle of change?
Pre-contemplation
Contemplation
Preparation
Action
Maintenance
Relapse
73
Whats the pre-contemplation phase of the cycle of change and what is the task for you as the clinician?
When the pt doesnt see a problem or a reason to change
As the clinician you need to promote engagement and form a positive relationship. Provide factual and personal information
74
Whats the contemplation phase of the cycle of change and what is the task for you as the clinician?
The pt thinks they might have a problem but are apprehensive about change
As the clinician you want to discuss about weighing the pros and cons of not drinking and explore possible alternatives
75
Whats the preparation phase of the cycle of change and what is the task for you as the clinician?
Pt i ready to engage in change process
As the clinician this is where you discuss options and treatments. You also need to arrange a starting date
76
Whats the action phase of the cycle of change and what is the task for you as the clinician?
When the pt and you see a noticeable change in behaviour
As the clinician you need to understand factors and strategies to support the new behaviour. Re-I force and support!
77
Whats the maintenance phase of the cycle of change and what is the task for you as the clinician?
A consolidation of change and new skills being developed
As the clinician you should support, encourage, provide support systems and design relapse prevention plans
78
Whats the relapse phase of the cycle of change and what is the task for you as the clinician?
When the pt goes back to drinking
As the clinician you want the pt to re-engage with services and support available, explore reasons for relapse, learn from lapse experience and review the relapse prevention plan
79
What framework can we use for helping with communication in motivational interviewing?
FRAMES
Feedback - on risk for alcohol problems
Responsibility - make person feel responsible for change
Advice - about reduction and changing
Menu - give options and a variety of strategies
Empathic interviewing - be understanding
Self efficacy - empower person to want to change
80
What are the aims of the national alcohol strategy?
Aims:
• crackdown on binge drinking culture
• Cut alcohol fuelled violence
• Lower number of people drinking to damaging levels
• Reducing the availability of cheap alcohol - minimum unit price for alcohol and a ban on the sale of multi-buy alcohol discounting
• Reduce alcohol advertising
81
Outline how negative and positive re-inforcement contribute to alcohol use disorders?
As you drink to chronic levels, GABA, glutamate, dopamine and serotonin receptors become less senseitive or neurones have fewer receptors due to down regulation = pt needs more to drink to get same effects = positive re-inforcement
Withdrawal symptoms the pt gets encourages the pt to drink again to avoid them = negative re-inforcement
82
How do you treat delirium tremens?
Oral lorazepam
If symptoms persist or cannot give orally then parenteral lorazepam or haloperidol can be given as adjunctive therapy
83
How do you treat alcohol withdrawal seizures?
Fast acting benzodiazepine such as lorazepam
84
Do short or long-acting benzos have a higher risk of withdrawal symptoms?
Short-acting benzos
85
What are some examples of short acting benzodiazepines?
Lorazepam
Midazolam
86
Give examples of long acting benzodiazepines?
Diazepam
Clorazepate
Chlordiazepoxide
87
What is Valium?
Diazepam (long lasting)
88
What is rohypnol?
Flunitrazepam (long acting)
89
What is Xanax?
Alprazolam (short acting)
90
What is wernicke-korsakoff syndrome?
A spectrum of disease with Wernickes encephalopathy being the acute, reversible stage and korsakoff syndrome being chronic and irreversibly.
Caused by a vitamin B1 (thiamine) deficiency
91
How does alcohol lead to decreased thiamine levels?
1. Interferes with the conversion of thiamine to its active form by blocking the phosphorylation
2. Ethanol prevents absorption of thiamine by reducing the gene expression for thiamine transporter 1 within the intestinal wall
3. Cirrhosis interferes with storage of thiamine within the liver
92
Other than alcohol misuse, what other causes of thiamine deficiency are there?
Inadequate intake - Malnutrition and anorexia
Inadequate absorption - Stomach cancer or IBD
Diet of mostly white rice, dialysis, Chronic diarrhoea and high doses of diuretics are risk factors also
93
What are the effects of wernickes encephalopathy?
Opthalmoplegia (nystagmus, double vision, eyelid drooping)
Ataxia (lose of muscle coordination)
Changes in mental state (confusion -> coma and death)
94
What are the effects of korsakoff syndrome?
Anterograde amnesia
Retrograde amnesia
Confabulation
Hallucinations
95
How do you diagnose wernicke-korsakoff syndrome?
Clinical impression from presenting sympotms
Blood tests for liver function, serum albumin to check general nutrition
LFTs
Examination of eyes
MRI to see degeneration of mamillary bodies
96
When should you treat wernickes encephalopathy and why?
Immediately to prevent korsakoff syndrome
97
How do you treat wernickes encephalopathy?
Pabrinex (thiamine IM)
Glucose once thiamine leaves have normalised
98
Why should you wait for thiamine levels to normalise before giving glucose to treat wernickes encephalopathy?
as without thiamine pyrophosphate, glucose will become lactic acid and this causes metabolic acidosis. (Wernickes can be precipitated by glucose administration in a thiamine-deficient patient)
99
How should you treat korsakoff syndrome?
Extended treatment with oral thiamine
Give vitamin supplements
Abstain from alcohol
Maintain healthy diet
100
What is beriberi?
A severe and chronic form of thiamine deficiency
101
What are the 2 main types of beriberi?
Wet and dry
102
What is wet beriberi?
It affects the cardiovascular system = tachycardia, SOB and leg swelling = eventually causes heart failure
103
What is dry beriberi?
Affects nervous system = numbness in peripheries, confusion, trouble moving limbs = eventually can cause muscle paralysis
104
What type of beriberi is wernicke-korsakoff syndrome?
Dry
105
What questionnaires do we use to see if there is dependance and an indication for chlordiapoxide?
SADQ - severity of alcohol dependence questionnaire
106
Why do we use long acting benzos for alcohol withdrawal treatment? And when do we use short acting?
Less chance of dependance
Short acting ones used in liver impairment
107
What is substance abuse?
A maladaptive pattern of substance use that results in a failure to fulfil work, home or school obligations; physically hazardous behaviour; legal proble,ss and recurrent interpersonal problems
108
What is harmful use?
A pattern of substance use that is harmful to physical or mental health
109
What is substance dependance?
A syndrome diagnosed if 3 or more of the following have been present at some time during the previous year…
1. A strong desire to take a substance
2. Difficulties in controlling substance-taking behaviour
3. Physiological withdrawal state when substance use has reduces or ceased; or continued use of substance to relieve or avoid withdrawal symptoms
4. Signs of tolerance
5. Neglect of other interests and activities due to time spent acquiring and taking substance, or recovering from it’d effects
6. Persistence with substance use despite clear awareness of harmful consequenuces
110
What is substance intoxication?
A transient substance-specific condition that occurs following use of psychoactive substance and features disturbances of consciousness, perception, mood, behaviour and physiological functions, and is closely related to dose levels
111
What effects does excessive alcohol use have on the metabolic and endocrine system?
Hypoglycaemia - as can increase insulin secretion
Hypomagnesaemia
Hypophosphataemia
Hyponatraemia
Hypokalaemia
Hyperlipidaemia
Hyperuricaemia
Alcohol induesed pseudo-Cushing syndrome
112
What are consequences of excessive alcohol consumption on the musculoskeletal system?
Acute and chronic myopathy
Osteoporosis
113
What are consequences of excessive alcohol consumption on the foetus?
Intrauterine growth retardation
Foetal alcohol syndrome
114
What is acute intoxication delirium?
A disorder characterized by the acute and sudden development of changes in attention, memory, language and/or perception that can be etiologically linked to the direct physiological consequences of substance intoxication
115
What is pathological intoxication?
An acute psychotic episode occurring in individuals whose tolerance for alcohol is low due to an unstable personality/epileptic tendencies, and relatively normal individuals who drink after being subjected to prolonged stress, debilitating illness, or an exhausting experience
The patient becomes confused and disoriented, and experiences hallucinations which lead to impulsive acts or outright violence
116
What is alcohol-induced dementia syndrome?
Chronic heavy alcohol use cans lead to mild-moderate impairment of memory, learning, Visio spatial skills and impulse control. It’s associated with cortical atrophy and ventricular enlargement
Hard to tell if this really is a true thing because its diffiuclt to separate the toxic effects of alcohol from brain damage caused by… years of malnutrition, alcohol associated head trauma, multi-organ dysfunction
117
What is alcohol-induced amnesia?
Korsakoff syndrome
118
What is alcohol-induced psyhcosis?
Heavy alcohol consumption can cause hallucinations and delusions which can be fleetinhg or more persistent. They are predominantly auditory hallucinations or visual. These syndromes are distinguished from intoxication/withdrawal delirium by the absence of clouding of consciousness
Clears with abstinence of alcohol
119
What proportion of drinkers experience significant anxiety symptoms?
1/3rd
120
What type of seizures are withdrawal seizures?
Tonic-clonic
121
How do you treat alcohol withdrawal syndrome in those with hepatic failure?
Lorazepam is preferred over chlordiazepoxide as it reduces risk of increased sedation
