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BDS3 PMHP > Alcohol Advice > Flashcards

Alcohol Advice Flashcards

1
Q

alcohol metabolism body distribution

A

Alcohol distributed throughout body water

Concentration in liver is greater because blood comes directly to it from the stomach and small intestine via the portal vein

Very little alcohol enters the body fat

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2
Q

alcohol absorption

A

Water soluble

Slowly absorbed from the stomach

More rapidly absorbed from small intestine

Rate of absorption quicker on empty stomach at concentration 20-30% (sherry)

Spirits (40%) delay gastric emptying and are absorbed more slowly

Aerated alcohol e.g champagne gets into system more quickly

Food retards absorption

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3
Q

alcohol metabolism %

A

90% metabolised in liver

2-5% excreted in sweat, urine or breath

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4
Q

alcohol metabolism stages

A

alcohol -> acetaldehyde

acetaldehyde -> acetate

acetate -> CO2 and water

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5
Q

blood alcohol concentrations variations

A

Varies according to age, sex, size and body build, previous exposure, type of drink and whether food is taken

Drugs like cimetidine will delay gastric emptying and reduce absorption
- for acid reflux

Drugs like antihistamines have the opposite effect (increase absorption)

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6
Q

women and blood alcohol levels

A

Lower levels of alcohol dehydrogenase in the stomach so more alcohol is absorbed before it has been metabolised

Alcohol crosses the placenta easily
- pregnant women shouldn’t drink – affect foetus – foetal alcohol syndrome

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7
Q

blood alcohol concentration timings

A

Peaks 1 hours after drinking on an empty stomach

Declines over the next 4 hours

Removed at rate of 15mg/100ml/hr

Detectable levels still present for several hours

After 3 pints of beer blood alcohol will be detectable in the morning

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8
Q

tolerance of alcohol in heavy drinkers

A

Normal metabolism increases

Microsomal ethanol oxidising system comes into play i.e. enzyme induction occurs, this system can also be induced by drugs
- gamma GT will be increased in heavy drinkers

in heavy drinkers with liver damaged enzyme production decreases

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9
Q

heavy drinkers with liver damage

A

enzyme production decreases

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10
Q

intoxication effect

A

mild sedative

mild anaesthetic

stimulates dopamine and serotonin

sense of wellbeing relaxation an dis-inhibition

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11
Q

current legal driving limit

A

Scotland 50mg/100ml blood (UK 80mg/100ml blood)

- risk of road accident double at 50mg/100ml as judgement is impaired

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12
Q

100mg/100ml blood alcohol makes person

A

people became elated and aggressive

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13
Q

effect of 200mg/100ml blood alcohol

A

slurred speech and unsteadiness

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14
Q

> 400mg/100ml blood alcohol effect

A

commonly fatal due to:

  • atrial fibrillation
  • respiratory failure
  • inhalation of vomit
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15
Q

genetic factors contribution to alcohol problems

A

genetic predisposition to development of alcohol problems (60%; 40% environmental)

4x increased risk of alcoholism in primary relatives

More common in monozygotic twin siblings

Adopted away children of alcoholics 4x increased risk

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16
Q

safe weekly alcohol limits

A

Men and women
- to keep health risks from alcohol to a low level it is safest not to drink more than 14 units a week on a regular basis

if you regularly drink as much as 14 units per week – it is best to spread evenly over 3 or more days

risk of developing a range of health problems (including cancers of mouth, throat and breast) increases the more you drink on a regular basis

pregnant women

  • no alcohol during pregnancy
  • can also cause problems with conception – both sexes
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17
Q

medical problems associated with chronic heavy drinking

areas (17)

A 
GI Tract 
Heart
Traumatic Injuries
Skin, muscles, nerves and bones
Blood
Chest
Gynaecological Problems
Obstetric problems 
Bleeding 
Poor Wound healing 
Drugs 
Patients with Hep C
Hormones and Metabolism 
Immune system 
Mental health 
Nervous system 
renal
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18
Q

alcohol effect on GIT

A

Acute gastritis

Liver problems

GI bleeding

Oral, oesophageal, stomach, bowel cancer

Pancreatic disease

Obesity and malnutrition

Vitamin deficiency
- folic acid, vit B1, B2, B6, E, and D

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19
Q

alcohol effect on heart

A

cardiomyopathy

cardiac arrhythmias

hypertension

increased triglycerides and LDL chloesterol

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20
Q

alcohol effect on skin, muscles, nerves and bones

A

acute or chronic myopathy

osteoporosis

osteomalacia

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21
Q

alcohol effect on blood

A

macrocytosis

thrombocytopenia

leucopenia

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22
Q

alcohol effects on drugs

A

drug metabolism and interactions

non-compliance

interactions also with illicit drugs

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23
Q

effect of alcohol on hormones and metabolism

A

can cause pseudo-Cushing’s syndrom

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24
Q

effects of alcohol on nervous system

A

epilepsy

Wernicke-Korsakoff syndrome

cerebral atrophy

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25
Q

oral problems in chronic heavy drinking (13)

A

Oral cancer
- Concurrent with tobacco use

Oral ulceration

Glossitis

Angular cheilitis

Gingivitis – nutritional def link

Dental neglect

Dental trauma – chaotic lifestyle

Lost denture

Salivary gland enlargement – sialosis
- xerostomia

Dental erosion

Bruxism

Poor wound healing and osteomyelitis

Suppression of immune system by alcohol

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26
Q

alcoholic liver disease prevalence

A

Fastest growing disease in the UK

Number of cases diagnosed in Scotland has doubled since 1996
- Lothian – 1996: 275 cases; 2006: 445 cases

Unusual

  • Most patients who drink heavily will not develop alcohol-related liver injury
  • 20% do
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27
Q

stages in alcoholic liver disease

A

normal
steatosis (fatty liver)
steato-hepatitis ->
cirrhosis (20%)

Habitual consumption of alcohol produces a spectrum of hepatic pathology, ranging from simple steatosis (fatty liver) on one extreme, to cirrhosis on the opposite end of the spectrum.

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28
Q

liver damage by

A

Alcohol and metabolites and by co-morbidity factors

Environment and host factors
- Age, sex, viruses, drugs, nutrition

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29
Q

steatohepatitis

A

a liver disease characterized by hepatic steatosis, inflammation, and increased hepatocyte death,

is usually an intermediate stage between simple fatty liver and cirrhosis

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30
Q

steatosis

A

is a very common result of chronic alcohol ingestion,

occurring in many, if not most, human beings and experimental animals that consume alcohol daily.

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31
Q

cirrhosis

A

relatively rare outcome of chronic alcohol ingestion (20% of heavy drinkers)

scar, nodules
- irreversible

alcohol most common cause in West

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32
Q

probability of mortality in ALD

A

probability of liver failure and death from steatohepatitis increase significantly in patients with associated hepatic fibrosis or cirrhosis.

Thus, the transition from simple steatosis to steatohepatitis appears to represent a rate-limiting step in the progression to cirrhosis and clinical liver disease in patients with alcoholic fatty liver disease.

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33
Q

common morbidties of cirrhosis

A

jaundice

ascites

bleeding

cachexia

infections

encephalopathy

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34
Q

5-year survival of cirrhosis

A

90% if stop drinking

60% if don’t stop drinking

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35
Q

death in those with liver cancer

A

death in most people with liver cancer within 10 years

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36
Q

cirrhosis affect on liver function

A

deranged liver function tests

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37
Q

liver disease and dentistry

A

Reduced synthesis of clotting factors in damaged liver

  • Combined with reduced absorption of vitamin K
  • II, VI, IX, X

Thrombocytopenia
- Due to splenomegaly, associated with portal hypertension

Megakaryocyte maturation is also reduced – leading to fewer platelets too

Platelet aggregation is reduced

Lead to prolong bleeding

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38
Q

clotting factors with reduced synthesis in liver disease

A

II
VI
IX
X

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39
Q

liver damage causes what problem

A

drug metabolism issues

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40
Q

drug metabolism in pts without liver damage but are heavy drinkers

A

Heavy drinking induces liver enzymes

This may increase the metabolism of some drugs

  • More rapid destruction
  • Reduced plasma concentration

Lack of effects

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41
Q

drug metabolism in pts with liver damage

A

reduced drug metabolism

- LA, analgesia, sedatives and antibiotics

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42
Q

alcohol effect on warfarin metabolism

A

enhanced metabolism if regular consumption of >3U/day

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43
Q

can alcohol be synergistic with drugs

A

yes - some drugs act with alcohol to produce synergistic effects

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44
Q

sedative effect of alcohol and drug metabolism

A

alcohol will interact with drugs producing a sedative effect on nervous system and increase or prolong the effect

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45
Q

paracetamol and alcohol

A

heavy drinker paracetamol can be converted to an intermediate metabolite which is very hepatotoxic

But Paracetamol is analgesic of choice in liver damage pts in regular dose
- NSAIDs higher chance of GI bleeding

46
Q

analgesic of choice in liver damage pts

A

Paracetamol is analgesic of choice in liver damage pts in regular dose
- NSAIDs higher chance of GI bleeding

47
Q

diulfiram metabolism

A

Disulfiram (Antabuse) inhibits alcohol dehydrogenase which normally converts acetaldehyde to acetate

  • Acetaldehyde builds up and nausea and vomiting occur if alcohol is taken
  • Unpleasant

Used in alcohol treatment – deterrent from drinking

Other drugs cause this reaction e.g. Metronidazole, cephalosporins, ketoconazole

If large amounts of alcohol are taken then cardiac arrhythmias and hypotensive collapse can occur

48
Q

drugs and liver damage

cause GI bleeding

A

Aspirin and NSAIDs
- Irritant to gastric mucosa

Alcohol is also a gastric irritant

Clotting may be deranged due to liver disease which exacerbates the problem

49
Q

alcohol and hep C

A

25% patients with hepatitis C will develop cirrhosis

Alcohol in any amount leads to more rapid development of severe liver disease
- Patients with hepatitis C should abstain from alcohol completely

50
Q

alcohol interaction with heroin

A

sedative effect

both alcohol and heroin are sedative
- taken together = increased effect

51
Q

alcohol interaction with cocaine

A

taken at the same time a new chemical is produced which is similar to cocaine but with a longer half life
- alcohol prolongs the effect of cocaine

both cardiotoxic – can lead to severe arrhythmias

52
Q

alcohol interaction with cannabis

A

absorption of alcohol reduced but combination will increase sensation of confusion and disorientation making accidents more likely

53
Q

alcohol interaction with amphetamines

A

alcohol will increase impairment of judgement

54
Q

alcohol interaction with ecstasy

A

alcohol increases intoxication but will reduce the potentially fatal fluid retention effect of ecstasy

55
Q

nutritional issues with alcohol

A

Alcohol is very calorific
- 6 pints of beer = 500kcals

Alcoholics are generally malnourished
- General neglect- Substitution of food with alcohol

Deficiencies of

  • Thiamine - beriberi, Wernicke’s encephalopathy
  • Folic acid - macrocytosis
  • Vitamin C-scurvy

Fat stomach but generally skinny and malnourished

56
Q

heart diseases linked to alcohol

A

cardiomyopathy

cardiac arrhythmias

hypertension

stroke

protective effects

57
Q

cardiomyopathy

A

Degenerative heart disease with no coronary artery disease
- Various aetiologies

Well-established complication of chronic alcohol abuse

Most cases asymptomatic

Can lead to arrhythmias, cardiomegaly and congestive heart failure (dyspnea and peripheral oedema)

may be due to accumulation of fatty acid ethyl esters (FAEE) in mitochondria

58
Q

cardiomyopathy management

A

supportive measures

abstinence from alcohol

59
Q

cardiac function in women Vs men

A

women can develop cardiac problems with less alcohol and lower duration of consumption

60
Q

cardiac arrhythmias

A

ECG changes can be marked

  • Atrial fibrillation
  • Prolonged Q-T interval
  • Inverted T waves
  • Heart block
  • Ventricular arrhythmias

‘Holiday heart syndrome’ and sudden death

61
Q

strokes and alcohol

A

Light to moderate alcohol consumption decreases the risk of ischaemic stroke.

Consumption of 5 or more drinks per day increases risk of stroke by 250-450%

62
Q

hypertension and alcohol

A

Generally low grade hypertension

Risk factor for stroke

Chronic intake of 30g/day or more alcohol

Hypertension reverses within 2 or 3 weeks of cessation of alcohol intake even in heavy drinkers

Portal hypertension

63
Q

cardio-protective effects of alcohol

A

Moderate alcohol intake is associated with decreased risks of coronary artery disease (CAD)
- Observed in ecological studies, case control investigation and in a number of large scale protective cohort studies in males and females

Relative risk for coronary heart disease in:
- non drinkers is 1
- moderate drinker is 0.5
1-2 units of alcohol 2-3 times per week
Benefit particularly in older men and post menopausal women

Alcohol decreases the atherogenic plaques both in humans and experimental animals

Alcohol consumption increases HDL cholesterol

Moderate alcohol consumption is the year prior to acute myocardial infarction (MI) is associated with reduced mortality following infarction

64
Q

alcohol protective effect

A

coronary artery disease

incidence of gallstones

macular degeneration

65
Q

oral cancer prevalence

A

2% of all cancers

75-80% of pts who have it frequently consume a fairly high level of alcohol

66
Q

smoking and alcohol link to oral cancer

A

act synergistically

heavy smoking and drinking increases risk of oral cancer by 38x

67
Q

why is the 5 year survival of oral cancer relatively low (45-55%)?

A

Don’t tend to go to dentist when first develops – general health neglect theme

Pre-existing problem with smoking and alcohol
- Initial lesion often ignored

Cancer often advanced at presentation
- lymph node involvement = indicates spread

68
Q

oral cancer Tx effect

A

Major surgery 9-10 hours + radiotherapy
- Permanent disfigurement, problems with speech, eating, drinking, socialising

leads to Depression -> more drinking

69
Q

how does oral cancer occur

A

Ethanol metabolite acetaldehyde promotes tobacco initiated tumours

Damages DNA and alters oncogene production

Alcohol facilitates absorption of carcinogenic substances across the oral mucosa

Partly due to thinning of oral mucosa due to nutritional deficiency

70
Q

alcohol link to violence and facial injury

A

57.6% of male and 21.4% of female victims of assault have consumed alcohol prior to their injury

24% of facial injuries in the UK result from violent behaviour, over half are alcohol related. Young men are at highest risk (1998)
- repeated more recently in Glasgow up to 80%

Facial injury can have long lasting physical and psychological effects
- 40% PTSD from facial trauma (Glasgow)

71
Q

effect on mental well being of facial injuries

A

Post Traumatic Stress Disorder

Facial injuries can result in psychiatric morbidity

  • lead to more Alcohol problems
  • ‘Vicious circle’
72
Q

types of dental trauma related to alcohol

A

broken teeth

lost teeth

damage to soft tissues

lost dentures

due to interpersonal violence or falls lined to alcohol

73
Q

apart from trauma other dental issue linked to alcholo

A

non carious tooth surface loss

74
Q

non carious tooth surface loss due to alcohol

A

Alcohol is very acidic

Gastro oesophageal reflux disease (GORD)-acid in alcohol directly relaxes the oesophageal sphincter

Vomiting

Multifactorial-bruxism

Restoration difficult until problem controlled
- a restorative nightmare?

75
Q

hazardous drinking

A

risks of alcohol problems are likely

76
Q

harmful drinking

A

problems associated with alcohol are actually present - medical, dental, social

77
Q

dependent drinking

A

alcohol is needed to function

78
Q

SIGN Guidelines 74 - role of HCP in alcohol

A

management of harmful drinking and alcohol dependence in primary care

“GPs and other primary health care professionals should opportunistically identify hazardous and harmful drinkers and deliver a brief (10 minute) intervention”

79
Q

screening

A

purpose of screening is to identify people who need more comprehensive assessment for substance misuse disorders.

It does so by uncovering indicators of serious substance-related problems among adolescent.

As such, it covers the general areas in a client’s life that pertain to substance use without making an involved diagnosis or assessment.

80
Q

why screen in healthcare setting

A

Alcohol related mortality and morbidity is high

Many morbidities related to alcohol, including effects on oral health

81
Q

morbidity

A

illness related to

82
Q

mortality

A

deaths related to

83
Q

skill required to screen

A

A basic working knowledge of drug/alcohol issues

Awareness of signs for potential problems

Training in interviewing techniques

Ability to listen to the views of the patient

Report writing skills

Awareness of services available

Recognition of confidentiality issues

84
Q

screening tools help to

A

standardised screening tests

85
Q

screening tools

A

basically questionnaires

  • very effective in detecting hazardous drinking and alcohol dependence
  • short, easily administered and easily scored
  • can be used by a wide range of professions
  • can be used opportunistically
86
Q

example screening tools for alcohol disorders

A 
AUDIT – the gold standard
PAT – used in A&E
FAST – most practical 
CAGE – not suitable for young people 
POSIT – good but 139 questions 
CRAFFT – specifically for adolescents

all have a good sensitivity and specificity across wide range of settings

87
Q

CAGE (ewing, 1984)

A

‘Yes’, ‘sometimes’ or ‘often’ to 2 or more may indicate an alcohol problem

  • Have you ever felt you ought to cut down on your drinking?
  • Do you get annoyed at criticism of your drinking?
  • Do you ever feel guilty about your drinking?
  • Do you ever take an early morning drink first thing in the morning to get the day started or eliminated the shakes?
88
Q

FAST (hodgson et al, 2002)

recommended for dental practice use

A

Each question is scored 0-4

Patient is FAST positive if the total score for all questions is > 3
- May only need to ask the first question

89
Q

AUDIT (WHO 2001)

scores

A

longer than FAST

0-6 	WOMEN non-hazardous safe levels
0-7 	MEN non-hazardous safe levels
7-13 WOMEN hazardous drinking
8-15 MEN hazardous drinking
14-20 WOMEN harmful drinking
16-19 MEN harmful drinking
>20 possibly dependent drinking 
seek specialist help
90
Q

what types of alcohol disorders are amenable to brief motivational intervention

A

hazardous drinking

harmful drinking

91
Q

what type of alcohol disorders is not amenable to brief intervention

A

dependent drinking

- needs specialist help

92
Q

readiness to change - the teachable moment is

A

time when people may be more receptive to change

It may be

  • After witnessing someone else being injured
  • After experiencing other negative consequences of drinking
  • Need to be able to relate the adverse event to drinking
93
Q

readiness to change

A

brief intervention will be most effective if the person receiving it is ready to change

tell by use of a readiness to change ruler

If not ready to change = intervention likely unsuccessful

94
Q

cycle of change stages

A

precontemplative

comtemplative

preparation

action

maintenance

replapse

95
Q

precontemplative

stage of change - Pt displays

A

‘what problem? There’s no need to change. My friends drink more than me’

96
Q

contemplation

stage of change - pt displays

A

‘I hear what you are saying. I know it’s bad for me, but I enjoy drinking’

listening

97
Q

preparation

stage of change - pt displays

A

‘I am going to cut down after new year/next week’

remove all from house

98
Q

action

stage of change - pt displays

A

‘I have cut down on my drinking’

not drinking in house, spacing drinks

99
Q

maintenance

stage of change - pt displays

A

‘I’ve only been drinking once a week for the last 6 months and have had no more than 2 drinks on that night’

100
Q

relapse

stage of change

A

Common – backwards in cycles, but still able to progress forward again

101
Q

brief motivational interventions

A

Behaviour change style of counselling

Non-judgemental

Typically lasts between 5 and 20 minutes

Suitable as an opportunistic intervention for patients whose main reason for contact is not their drinking behaviour i.e. dental patients

Pioneered by Miller and Rollnick (1991), who see BMI as not a technique but as a way of being with people – 2 way conversation
- Patient encourage to recognise ambivalence between their actual and ideal behaviour and that the responsibility of change rests with them

102
Q

FRAMES - framework for BMI

A

Feedback is given to patient about behaviour

Responsibility for change is placed on the patient

Advice to change is given by practitioner

Menu of self-directed changed options/treatment is offered

Empathic style using warmth, respect and understanding

Self-efficacy is engendered to encourage change

103
Q

F in FRAMES

A

Feedback is given to patient about behaviour

104
Q

R in FRAMES

A

Responsibility for change is placed on the patient

105
Q

A in FRAMES

A

Advice to change is given by practitioner

106
Q

M in FRAMES

A

Menu of self-directed changed options/treatment is offered

107
Q

E in FRAMES

A

Empathic style using warmth, respect and understanding

108
Q

S in FRAMES

A

Self-efficacy is engendered to encourage change

109
Q

14 units of alcohol equivalent to

A

6 pints of beer (4% abv)

6 glasses of wine (13%)

14 shots of a spirit (40%)

110
Q

motivational interviewing should be

A

a conversation

short

non-judgemental

motivational

aimed at changing behaviour

111
Q

FRAMES

BMI approach

A 
Feedback
Responsibility
Advice
Menu of options
Empathic
Self-efficacy

BDS3 PMHP (14 decks)

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