Alcohol

Question 1

What are the 3 drugs for alcohol maintenance and which one is usable for pts w/ liver damage?

Answer 1

1) Disulfiram
2) Naltrexone
3) Calcium Acetylhomotaurinate - Acomprosate - No Liver Toxicity!!!

Question 2

What is Physiologic Depenedence?

Answer 2

State of the body as a result of ongoing exposure to a substance

Definitely Present if person displays tolerance or withdrawal but NOT synonymous with addiction

Question 4

_Definitions: _

Tolerance

Withdrawal

Sensitization

Answer 4

Tolerance: The need for increasing amounts of a substance for the same effects

Withdrawal: Problems (physical or psychological) that occur after the cessation of use of a substance were body has tolerance

Sensitization: Reverse Tolerance …increased response to same amount of drug

Question 6

What are the Intoxications you can die from?

Answer 6

Nicotine, Cocaine, Amphetamine

Benzos, Alcohol, Barbituates

Opioids, PCP, Steroids

Inhalants and designer drugs

Question 8

What are the Withdrawals you can die from?

The “B.A.B.”s + O

Answer 8

Alcohol

Barbituates

Benzos

Opioids (debiltated and infants)

Question 10

How is alcohol absorbed? What are factors that alter absorption?

Answer 10

Rapidly absorbed in GI tract and sometimes even starting in the mouth

Passive Diffusion that is concentration dependent (Rapid at 20-30% and slower above that)

Depends on stomach content!!!!!

Summary of Factors altering absorption:

• Volume and character of beverage
• food
• fat content
• time course of ingestion
• individuals
• H2 Blockers

Question 12

How does alcohol distribute in the body?

Answer 12

EtOH is highly water soluble and therefore distributes water to all tissues and accumulates in high blood flow organs (THE BRAIN!)

Enters Fetal circulation too!!!

Alcohol moves to organs w highest water content

Question 14

Describe the metabolism of Ethanol: What are the major enzymes players? What are some factors that cause differences in metabolism?

Answer 14

Metabolized in liver in 2 big steps controlled by 2 enzymes: 1) Alcohol Dehydrogenase to Acetaldehyde and Aldehyde Dehydrogenase

Gender Differences matter

• For any given amount, women have higher BAC and slower metabolism

Race and Ethnicity Matters:

• ADH enzyme variants matter - especially asians!!

SEE PICTURE

Question 16

How is alcohol eliminated? aka what are the pharmacokinetcs?

Answer 16

Most alcohol elimination is Zero Order elimination until at very low amounts (10mg/dl) where it is First Order

Question 18

What are the important BACs to know for Alcohol?

Answer 18

0. 02 - mood elevation and slight muscle relaxation; DUI if under 21
1. 08 - DUI
2. 5 Death

[amounts are different in tolerant people]

Question 20

What are effects of alcohol intoxication?

What is treatment?

Answer 20

BEING DRUNK!!! flushing, diuresis, warmth, nystagmus etc

Treatment supportive - protect airway, electrolytes, trauma (CHECK HEAD FOR TRAUMA), COFFEE DOESNT CUT IT!

Question 22

What are the GI effects of Alcohol Intoxication?

Answer 22

stimulates gastric juices - high acid and low pepsin

Low amounts stimulate GI motility and high amounts depress it

can cause N/V that is both central and peripheral

GI IRRITANT

Question 24

How does taking ASA affect Alcohol absorpiton?

Answer 24

MORE alcohol is absorbed when also using ASA

ASA inhibits gastric ADH!!!!

Both are more likely to cause GI irritation and are local irritants!

Question 26

What are CV effects of Alcohol?

Answer 26

Smaller amounts - transient increase in pulse, CO, BP and sub-cutaneous vasodilation

Then Hypotension

DANGER in cold weather!!!!

Question 28

What’s the more important factor in Alcohol withdrawal from chronic use?

Answer 28

Absolute alcohol level is less important compared to the relative decreases in that level which are important bc tolerance changes dependence on BAC

Question 30

What is the staging/symptoms of Chronic alcohol withdrawal? What is the final result and what can kill you?

Answer 30

Stage 1 - (w/in 24 hours and ablates by 48) - Shakey/tremor, HTN, tachycardia, sweating, N, Hyperactive reflexes, Fever, anxiety, derealization, clowdy sensorium, insomnia, HA –- Hangover

Stage 2 - (w/in 48 hours) more severe Stage 1 symptoms + HALLUCINATIONS - people know that something is weird - mostly auditory and are non-life-threatening

Pts have non-threatening hallucinations but intact reality testing

Stage 3 - (w/in 72 hrs and can last 3-7 days or more!) = Delirium Tremens - Need to prevent it - MORE hallucinations that are visual/tactile/auditory/olfactory and Threatening!!!!

OR have Seizures - tonic clonic (can be seen up to 1 week later) that are self-limited and can occur depsite normal vital signs

Delirium tremens or Seizures can be lethal

Question 32

What are some criteria that mandate in-patient detox?>

Answer 32

History of DT or Seizures when stop drinking

dehydration, malnutrition, infection

CV collapse or arrhythmias

Hallucinatoins

Trauma

Hepatic Decompensation

Wernicke’s Encephalopathy

Fever, Tremor, Tachycardia

Question 34

What can you use in the treatment of Alcohol withdrawal?

Answer 34

Supportive measures

correct fluid imblances

Benzos!!! Diazepam for a smoother taper

(Or barbituates)

+ Beta-blocker or Anti-convulsants (carbamazepine) so you can use less BZD

Question 36

What is Wernicke? Why is it dangerous? What are some signS?

Answer 36

Less result of EtOH and more of nutrient deficiency in Thiamine

Can progress to Alcoholic-Induced Persisting Amnestic Disorder - Korsakoff which is irreversible

Nystagmus, Lateral Gaze Palsy, Ataxia, Confusion, Diplopia

Question 38

What are primary diseasesa from chronic alcohol use?

What are secondary diseases from chronic alcohol use?

Answer 38

Primary - Withdrawal

Cardiomyopathy!!!! Gastritis, Liver cirrhosis, neuropathy

Secondary -

Cancer, DB, Pancreatitis, Pneumonia/influenza/TB, malnutrition, Respiratory disease

Question 40

What are some biological markers for chronic heavy drinking?

Answer 40

LFTs - AST/ALT

GGT!!!!

CDT and MCV

Question 42

What are endocrine effects of chronic alcohol use

Answer 42

Decreased testosterone in men - loss of secondary sex characteristics leading to impotence and sterility + testitcular atrophy and gynecomastia

Women - disruption of ovarian function

Question 44

What do you see in FAS?

Answer 44

microcephaly

Prenatal Growth deficiency

Short, palpebral fissures

Question 46

What are the 3 maintenance treatments for Alcoholism and how do each of them work?

Answer 46

1) Disulfiram - Blocks Aldehyde Dehydrogenase so build up acid aldehyde ….N/Dizziness/HA/Flushing
2) Naltrexone - Mu Antagonist to decrease reinformcement you get when someone drinks
3) Calcium Acetylhomotaurinate (Acomprosate/Campral) - NMDA glutamate Rec modulator - decreases cravings and triggers

Question 48

What are the pros and cons of disulfram?

Answer 48

Pros - makes you feel like shit if you drink on it = Adverse Conditioning

Cons - occasionally can cause heart problems and death if you drink on it

HAVE TO TAKE IT!!!!

Side Effects: Drowsiness, lethargy, HTN, peripheral neuropathy

Liver Toxicity!

Question 50

What are the pros and cons of naltrexone?

Answer 50

Pros - decreases reinforcement you get w/ drinking

generally well tolerated

*Can get long-acting injection! *

Cons - occasional N/ HA sedation or anziety

Rarely - increase in LFT!

Question 52

What are the pros and cons of Calcium Acetylhomotaurinate aka Acomprosate?

Answer 52

Pros: Decreases cravings by normalizing glutamate levels to help w craving and trigger

NO LIVER TOXICITY

Cons: FDA WARNING INCREASED SUICIDE AND VIOLENCE

Side Effects: Diarrea and nausea

3x/day dosing