Alcohol

Question 1

major risk factors for alcoholism & alcohol abuse

Answer 1

wrecks
alcoholic liver disease
14 million people have signs of alcohol abuse or alcohol dependence
700,000 people are in treatment
Increased risk of cancer
1/5 patients visiting a physician will exhibit ‘at risk’ or problem drinking: this will affect treatment plan, how diseases work, how drugs work, etc
2x more undergrads will die from alcohol related illness compared to those recieving professional degree

Question 2

*Unique quality of alcohol:

Answer 2

both a stimulant and a sedative (based on peak BAC)
Acts as a stimulant/anxiolitic (bc of GABAa receptor activation) on the ASCENDING limb, and this is why *you drink (loading dose, and then spaced out drinks in an effort to STAY ON THE ASCENDING LIMB)
Acts as a sedative (inhibit nmda receptors) on the Descending limb, and this is when you go home (or show up in the ER)
Thus: physicians say alcohol is a sedative- b/c that’s when people show up in the ER

Question 3

Note about the BAC curve:

Answer 3

you can have a .08% BAC 2X on the BAC curse, once on the way up, once on the way down, and you will feel completely different “subjectively” based on the Time and Dose (way up still talkative, engaged, energized, and on the way down sedated, woozy, etc

Question 4

diff between cocaine and alcohol

Answer 4

Alcohol can allosterically activate GABAa: antianxiety, 5HT: nausea, or allosterically inhibit NMDA: angry, confused

Question 5

Ethonal can __________ GABAa, it can also __________ NMDA receptors

Answer 5

allosterically activate and enhance; allosterically inhibit

Question 6

Acute receptor sensitivity to the direct allosteric effects of Ethanol is concentration dependent

Answer 6

a little won’t do much, more will cause more effects, etc

Question 7

Alcohol alters brain activity in several regions and thus

Answer 7

it both stimulates and suppresses different brain regions depending on the compliment/concentration of receptors

Question 8

Alcohol vs cocaine:

Answer 8

Targets are different, but effect is the same

people drink for the same reason they do coke, it increases the dopamine from the nucleus accumbens in the brain’s reward system; note: cocaine prevents the transport (vaccumming up) of coke, and alcohol stimulates the release of dopamine

Question 9

the chance of developing alcoholism is greatly increased if:

Answer 9

a person begins drinking at an age before the prefrontal cortex is fully formed and developed

Question 10

The systems that are inhibited by alcohol______ if alcohol is around all the time, what does the brain do? So, one allostasis response is to _______

Opposite is true for __________: if alcohol is always around, and it causes too much activation, I’m going to ________

Answer 10

• (NMDA or Ka receptors), Makes more receptors! create new receptors to compensate

GABAa receptors and 5HT receptors, downregulate (make less of them)

Question 11

Regarding allostasis, what happens when you stop drinking after allostatic changes have taken place?

Answer 11

Then you have too few of the receptors that were facilitated by alcohol, and too many of the systems that were inhibited- so, alcohol withdrawl causes seizures (too many NMDA receptors and too few GABAa receptors)

Question 12

long term effects of alcohol:

Answer 12

Your ability to say no to drinking is greatly diminished, as well as your short term memory, etc
*ability to access the risk, associated with continued consumption, and to understand that it’s a bad idea to drive, lose your job, family, etc is all incredibly diminished by the drug

Thus: alcohol illness is just as much of a psychiatric illness as it is anything else

Question 13

If there have been way too many nmda receptors made during drinking,

Answer 13

when you stop, those receptors kill off the brain neurons

Question 14

long term psychological effects of drinking:

Answer 14

*Altered Subjective Responses to Alcohol (find drinking much more stimulating than I used to)
Cognitive dysfunction: can’t make normal risk assessments
Neurotoxicity: increased nmda receptors that no longer have alcohol will destroy and kill brain neurons

Question 15

How do you decide if there’s a problem?

Answer 15

Failure to fulfill major work, school, or home responsibilities
Drinking when physically dangerous
e.g., while driving a car or operating machinery, skiing, etc.
Recurring alcohol-related legal problems
e.g., being arrested for DUI or hurting someone while drunk

Question 16

Acamprosate (Campral

Answer 16

princess di driver, only works if ABSTINENT, not if you’re drinking

Question 17

Acute ethanol drinking:

Answer 17

alters the activity of many neurobiological systems, so it’s very hard to treat because it acts on so many different targets

Question 18

48 yo is drinking up to 6 beers a night and 12 on weekends. A year ago he had his liscense suspended for drunk driving, his marriage is failing, he was diagnosed with a gastric ulcer, he admits to having a problem, and has tried quitting on numerous occasions. He finds that he experiences insomnia if he does not drink for more than 2 days
why is thi sdependence rather than alcohol abuse?
the patient can’t stop drinking despite knowledge of its harmful effect and his desire to quit
high quantity of alcohol consumed on a regular basis
the patients history of drunk driving
the fact that the patient cannot sleep if he doesn’t drink
a medical complication due to drinking

Answer 18

the patient’s inability to stop despite knowledge of its harmful effect and his desire to quit

his inability to quit drinking regardless of his desire to quit or knowledge of harm best differentiates dependence from abuse. Neither dependence nor abuse is determined based on quantity of alcohol consumed. The patient’s statement that he cannot fall asleep when he tried to quit drinking does imply physiologic dependence, but the alcohol dependence criteria can be meet “WITHOUT PHYSIOLOGIC DEPENDENCE”

Question 19

A patient says he simply cannot control his cravings to have too much alcohol. Which of the following agens has shown some success in decreasing cravings for alcohol?
fluoxetine
disulfiram
naltrexone 
bupropion
diazepam

Answer 19

naltrexone (better than camprosate)

Question 20

a man enrolls in an outpatient rehabilitation program for which he is required to attend 3 metings per week. While he is interested in medication to minimize his risk of relapse, he admits to being "very forgetful" with medications. Which of the following medications would be most appropriate?
acamprosate
disulfiram
lorazempam
naltrexone
sertraline

Answer 20

naltrexone, an opiod antagonist that has been shown to help reduce craving, maintain abstinence aand reduce heavy drinking. Snother advantage is it is given in long-acting injectable form, beneficial for forgetful patients. Acamprosate has also demonstrated benefit in promoting abstinence, the evidence is not as strong as for naltrexone.

Question 21

48 yo is brought to the ED. She is unresponsive to questions, stubles aroiund the room, is agitated, smells of alcohol, and is not cooperative. Administration of what mediine is most appropriate for initial treatment?
antipsychotic
benzodiazepine
disulfiram
glucose
thiamine

Answer 21

thiamine
patient has wernicke encephalopathy, characterized by the triad of delirium, ataxia, and ophthalmoplegia. Thiamine must be given first

Question 22

48 yo is brought to the ED. She is unresponsive to questions, stubles aroiund the room, is agitated, smells of alcohol, and is not cooperative. Upon questioning you find the patient has drank heavily for 30 years, has started preferring alcohol to meals, and has started losing weight.
which is most likely found on mental status exam?
confabulation
delusions
elevated affect
fluctuating consciousness
loose associations

Answer 22

confabulation:
the patient has a long history of heavy regular alcohol use and likely malnutrition. A common sequelae of this chronic thiamine deficiency resulting in korsakoff syndrome: anterograde amnesia, memory impairment, and confabulation

Question 23

a 47 yo has a history of dependence upon alcohol. Which of the following signs is most characteristic of early alcohol withdrawl?
decreased bp
hypersomnia
persistent hallucinations
tremor
increased appetite

Answer 23

persistent tremor
vital signs are elevated in alcohol withdrawl bc of autonomic hyperactivity. patients will usually have insomnia as a result, not hypersomnia.

Question 24

44 yo comes to ED and family member reports he has been living off alcohol and drugs and nothing else for weeks. The ED nurse is about to go in to draw blood from the patient and offer him food. Most important thing to do:
be sure liver function tests are included
listen for mumer
administer lorazepam prophylactically for probably agitation
administer thiamine
get a B12 vit level

Answer 24

Serious chronic alcoholics often take in calories from little else besides alcohol and are thus at risk for thiamine deficiency. If a thiamine-deficient patient is given food, he will develop wernicke encephalopathy from the body’s attempt to metabolize glucose in the absense of thiamine.

Question 25

44 yo comes to ED and family member reports he has been living off alcohol and drugs and nothing else for weeks. The ED nurse is about to go in to draw blood from the patient and offer him food. How will the man's underlying condition be best treated in an acute medical setting
bensodiazepines
barbiturates
clonidine
phenytoin
disulfiram

Answer 25

benzodiazepines
This man is probably suffering from alcohol withdrawl and bc benzos and alcohol have a near-identical mode of action in their modulation of GABA receptors in the brain, it is the best choice

Question 26

a 56yo man with a history of hep c and alcoholim tells you he wants to quit drinking and first detox. In a patient with alcoholism, in whom you suspect impaired liver functino, the most appropriate drug to treat withdrawl symptoms is:
phenobarbital
chlordiazepoxide
lorazepam
alprazolam
clonidine

Answer 26

lorazepam

in cass of suspected liver impairment, it is advisable to use a benzo that minimally metabolized in the liver.

Question 27

a 52 yo man is admitted to the hospital 36 hrs earlier for an emergency appendectomy. The man is very agitated, and is talking nonsence to the nurse. You sujspect alcohol withdrawl. Which receptor is most closely associated witih these symptoms
D2
D4
GABAa
GABAb
5HT2

Answer 27

GABAa
in the cns, GABA is an inhibitory nt. At the postsynaptic GABAa receptor, GABA faciliatates chloride ion influx into a cell via a chloride channel, resulting in inhibition of that neuron. Alcohol and benzodiazepines both allosterically modulate the GABA-A receptor to facilitate GABAergic inhibition. Abrupt removal of alcohol or benzodiazepines after prolonged use results in a relative deficit of GABAergic inhibition, which can lead to anxiety, insomnia, delirium, and seizures