Alcohol Abuse

Question 1

What is alcohol abuse?

Answer 1

Consumption of alcohol at level sufficient to cause physical, psychiatric and/or social harm.

• Binge drinking over twice the recommended level of alcohol per day in one session.
• Harmful alcohol use defined as drinking above safe levels with evidence of alcohol-related problems

Question 2

What are risk factors for alcohol abuse?

Answer 2

• Genetics
• Being male
• Younger adults
• Lack of facial flushing
• Life stressors

Question 3

What are the aetiologies/pathphysiologies of Alcohol abuse?

Answer 3

• Affects neurotransmitter systems in brain: Pleasurable and stimulant effects of alcohol mediated by dopaminergic pathway in brain. Repeated, excessive alcohol ingestion sensitizes this pathway and leads to development of alcohol dependence
• Craving experiences are linked to dopaminergic, serotonergic, glutamatergic and noradrenergic system that mediate withdrawal
• Social learning theory suggests imitation of relative or friends are linked to drinking behaviour. Operant conditioning deters or perpetuate behaviour

Question 4

What are clinical features of Alcohol intoxication?

Answer 4

• Slurred speech
• Labile affect
• Impaired judgement
• Poor co-ordination

In severe cases

• Hypoglycaemia
• Stupor
• Coma present.

Question 5

What is the Edward and Gross criteria for alcohol dependence?

Answer 5

• Subjective awareness of compulsion to drink
• Avoidance or relief of withdrawal symptoms by further drinking
• Withdrawal symptoms
• Salience: drink-seeking behaviour predominates
• Reinstatement of drinking after attempted abstinence
• Increased tolerance to alcohol
• Narrowing of drinking repertoire

Question 6

What is the mechanism of action that results in alcohol withdrawal?

Answer 6

• Chronic alcohol consumption enhances GABA mediated inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors.
• Alcohol withdrawal is thought to be lead to the opposite (decreased inhibitory GABA and increased NMDA glutamate transmission)
• Long term exposure to alcohol causes down regulation of inhibitory GABA receptors and up-regulation of excitatory glutamate receptors so when alcohol is withdrawn, CNS hyper excitability occurs.

Question 7

What are features of alchohol withdrawal?

Answer 7

• Symptoms start at 6-12 hours: tremor, sweating, tachycardia, anxiety, malaise, nausea, insomnia, transient hallucinations, autonomic hyperactivity
• Peak incidence of seizures at 36 hours.
• Peak incidence of delirium tremens is at 48-72 hours

Question 8

What are symptoms of Delirium Tremens?

Answer 8

• Cognitive impairment
• Paranoid delusions
• Coarse tremor
• Confusion
• Delusions
• Auditory and visual hallucinations
• Fever
• Tachycardia.
• Dehydration and electrolyte disturbances are features.
• Lilliputian halluciantions can occur

Question 9

How are patients with alcohol withdrawal managed?

Answer 9

• Patients with a history of complex withdrawals from alcohol (i.e. delirium tremens, seizures, blackouts) should be admitted to hospital for monitoring until withdrawals stabilised
• Alcohol detoxification regime offers controlled withdrawal if possible, in the community. If severe then as inpatient.

Question 10

What is the medical management of Alchohol withdrawal?

Answer 10

• First-line: Benzodiazepines e.g. chlordiazepoxide. Lorazepam may be preferable in patients with hepatic failure. Typically given as part of a reducing dose protocol. Carbamazepine also effective in treatment of alcohol withdrawal.
• Haloperidol for any psychotic features
• Intravenous Pabrinex to prevent Wernicke’s encephalopathy (thiamine can also be given orally)

Question 11

What is the ICD-10 for Alchohol withdrawal syndrome?

Answer 11

A. General criteria for a withdrawal state met:

• (1) clear evidence of recent cessation or reduction of substance after prolonged or high level usage;
• (2) not accounted for by medical or mental disorder.

B. Any three of the following: tremor, sweating, nausea/vomiting, tachycardia/ BP, headache, psychomotor agitation, insomnia, malaise, transient hallucinations, grand mal convulsions.

Question 12

What is the CAGE questionnaire used for?

Answer 12

Useful tool for screening alcohol dependance. Patient has a problem if they say ‘Yes’ to 2 or more questions

• C – Have you ever felt you should Cut down on your drinking?
• A – Have people Annoyed you by criticizing your drinking?
• G – Have you ever felt Guilty about your drinking?
• E – Do you ever have a drink early in the morning to steady your nerves or wake you up? (Eye opener)

Question 13

What are investigations for Alcohol abuse?

Answer 13

• CAGE questionnaire and establish drinking pattern and quantity
• Bloods: blood alcohol level, GBC, U&Es, LFTs, Blood alcohol concentration, Vitamin B12/Folate/TFTs, Amylase, Hepatitis Serology, Glucose
• Alcohol questionnaire: AUDIT, SADQ, FAST screening tool
• CT head if head injury is suspected
• ECG for arrythmias

Question 14

What is the management of Alcohol Dependance?

Answer 14

• Motivational interviewing and CBT
• Pharmacological: Disulfiram, Acamprosate, Naltrexone
• Alcoholic Anonymous: 12 step approach using psychosocial techniques to change behaviours. Each person has a sponsor
• Raising tax on alcohol, restricted advertising or sales and more education

Question 15

What are complications of alcohol abuse?

Answer 15

• Cirrhosis
• Decompensated liver disease
• Wernicke’s encephalopathy
• Korsakoff’s psychosis

Question 16

What is Wernicke’s Encephalopathy?

Answer 16

• Acute encephalopathy due to thiamine deficiency presenting with delirium, nystagmus, ophthalmoplegia, hypothermia and ataxia. Urgent treatment with IV Pabrinex required or progresses to Korsakoff’s psychosis

Question 17

What is Korsakoff’s Psychosis?

Answer 17

Profound, irreversible short-term memory loss with confabulation and disorientation to time