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BDS3 - PMHP > Alcohol Advise > Flashcards

Alcohol Advise Flashcards

1
Q

how is alcohol distributed in the body

A

Alcohol distributed throughout body water

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2
Q

why is alcohol concentration greater in the liver

A

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

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3
Q

explain alcohol absorption in the body

A
  • Alcohol is water soluble
  • Slowly absorbed from the stomach
  • More rapidly absorbed in small intestine

• Rate of absorption quicker on empty stomach at concentration of 20-30% (sherry) Ie if you haven’t eaten anything then you will absorb alcohol much more quickly as food helps to slow down the absorption
[Food retards absorption]

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4
Q

what concentration of alcohol is absorbed most quickly

A

○ 20-30% is the concentration of alcohol which is most quickly absorbed which are things like fortified wines and sherry

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5
Q

how fast are spirits absorbed

A

• Spirits (40%) delay gastric emptying and are absorbed more slowly
○ Vodka, gin, whiskey

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6
Q

how fast does aerated alcohol absorb

A

• Aerated alcohol eg champagne gets into the system more quickly
○ Ie alcohol with bubbles in it

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7
Q

where is alcohol metabolised

A

90% metabolised in liver

2-5% excreted in sweat, urine or breath

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8
Q

how is alcohol metabolised

A
  • Alcohol —> acetaldehyde
  • Acetaldehyde —-> acetate
  • Acetate —–> CO2 and water
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9
Q

what does blood alcohol concentration vary according to

A

Varies according to age, sex, size and body build, previous exposure, type of drink and whether food is taken
Previous exposure is important because you do develop tolerance

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10
Q

what effect does drugs have on blood alcohol concentration

A

• Drugs like cimetidine will delay gastric emptying and reduce absorption
○ These types of drugs might be taken for acid reflux

• Drugs like antihistamines have the opposite effect
These drugs increase the rate of absorption

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11
Q

why does alcohol have an effect on women more quickly

A

• Women have a smaller blood volume than men
○ Because generally they are smaller

• They have lower levels of alcohol dehydrogenase (enzyme) in the stomach, so more alcohol is absorbed before it has been metabolised
○ Alcohol dehydrogenase helps to break down alcohol

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12
Q

why should pregnant women not drink alcohol

A

• Alcohol crosses the placenta easily
Pregnant women should not drink at all as it can affect the foetus

Be familiar with conditions like foetal alcohol syndrome (can have a life long effect on babies who’s mother drinks heavily)

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13
Q

when does blood alcohol concentration peak

A

Peaks 1 hour after drinking on empty stomach

Declines over next 4 hours

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14
Q

what is the rate that alcohol is removed from the body

A

Removed at rate of 15mg / 100ml / hour

Detectable levels still present for several hours

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15
Q

explain tolerance in heavy drinkers

A

• Normal metabolism increases
Ie the rate at which you metabolise alcohol increases

• Microsomal ethanol oxidising system in the liver comes into play
Ie enzyme induction occurs
○This system can also be induced by drugs (gamma GT will be increased in heavy drinkers)

• In heavy drinkers with liver damage, enzyme production decreases
[As the liver is damaged there isn’t as much liver to produce the enzymes]

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16
Q

explain how alcohol causes intoxication

A
  • Mild sedative
  • Mild anaesthetic
  • Stimulates dopamine and serotonin
  • Gives sense of wellbeing relaxation and disinhibition
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17
Q

what is the current legal driving limit in the UK

A

80 mg / 1000ml is current legal driving limit in UK BUT risk of road accident doubles at 50mg / 100ml as judgement is impaired

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18
Q

what is the legal limit in scotland

A

Limit in Scotland is 50mg / 100ml

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19
Q

what effect does alcohol have at 100mg / 100ml

A

100mg / 100ml people become elated and aggressive

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20
Q

what effect does alcohol have at 200mg / 100ml

A

200mg / 100ml slurred speech and unsteadiness

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21
Q

what effect does alcohol have at >400mg / 100ml

A

> 400mg / 100ml commonly fatal due to atrial fibrillation, respiratory failure or inhalation of vomit

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22
Q

what are the genetic factors to be considered for alcohol problems

A

There is a genetic predisposition to development of alcohol problems

○ 4x increased risk of alcoholism in 1˚ relatives
§ Ie higher risk if your relative is an alcoholic

○ More common in monozygotic siblings

○ Adopted away children of alcoholics 4x increased risk
§ Ie if you are a child of an alcoholic and you are adopted, you still have a 4x increased risk of developing alcohol problems

○ 60% of alcohol problems have a genetic link
○ 40% of problems are due to the environment people find themselves in

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23
Q

what id the recommended amount of weekly units of alcohol for men and women

A

14 units

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24
Q

why is there a recommended limit for alcohol intake

A

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

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25
Q

should you drink all 14 units in one day?

A

If you regularly drink as much as 14 units per week, it is best to spread your drinking evenly over 3 days or more

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26
Q

what happens to your risks if you drink on a regular basis

A

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

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27
Q

what GI Tract problems are associated with chronic heavy drinking

A

○ Acute gastritis
○ Liver problems
○ GI bleeding
○ Oral, oesophageal, stomach, bowel cancer
○ Pancreatic disease
○ Obesity and malnutrition
○ Vitamin deficiency ~ folic acid, vitamin B1, B2, B6, E, B1 and D

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28
Q

what heart problems are associated with chronic heavy drinking

A

○ Cardiomyopathy
○ Cardiac arrhythmias
○ Hypertension
○ Increased triglycerides and LDL cholesterol

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29
Q

what traumatic injuries are associated with chronic heavy drinking

A

accidents and violence

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30
Q

what skin, muscles, nerves and bones problems are associated with chronic heavy drinking

A

○ Acute or chronic myopathy
○ Osteoporosis
○ Osteomalacia

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31
Q

what drug problems are associated with chronic heavy drinking

A

○ Drug metabolism
○ Drug interactions
○ Non-compliance
Interactions with illicit drugs

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32
Q

what nervous system problems are associated with chronic heavy drinking

A

○ Epilepsy
○ Wernicke-korsakoff syndrome
○ Cerebral atrophy

33
Q

what bleeding problems are associated with chronic heavy drinking

A

○ Macrocytosis
○ Thrombocytopenia
○ Leukopenia

34
Q

what other medical problems are associated with chronic heavy drinking

A
  • Chest
  • Gynaecological problems
  • Obstetric problems
  • Bleeding
  • poor wound healing
  • patients with hepatitis C
  • immune system
  • mental health
  • renal
35
Q

what hormone and metabolism problems are associated with chronic heavy drinking

A

Pseudo-cushing’s syndrome

36
Q

what are oral problems associated with chronic heavy drinking

A
  • Oral cancer [Concurrent tobacco use]
  • Oral ulceration, glossitis, angular cheilitis, gingivitis - nutritional deficiency
  • Dental neglect
  • Dental trauma
  • Lost dentures
  • Salivary gland enlargement [Sialosis]
  • Xerostomia [Can lead to dental caries]
  • Poor wound healing and osteomyelitis
  • Suppression of immune system by alcohol
  • Dental erosion [Alcohol is very acidic]
  • Bruxism
37
Q

what are the causes of liver disease

A
  • alcohol and metabolites
- co-morbidity factors (environment and alcohol factors)
~ age
~ sex
~ viruses
~ drugs
~ nutrition
38
Q

what is the spectrum of alcoholic liver disease

A

normal liver

reversible to steatosis (fatty liver)
reversible because the liver repairs itself

still reversible but less so to steatohepatitis
more serious

irreversible to cirrhosis (this occurs in the 20% who have significant liver damage = not really reversible because the liver is scarred and replaced with fibrous tissues)
can improve the function a little but won’t return to normal

39
Q

what problem does liver disease cause in dentistry

A

• Reduced synthesis of clotting factors in damaged liver
○ Combined with reduced absorption of vitamin K
○ Clotting factors affected are II, VII, IX, X

• Thrombocytopenia due to splenomegaly associated with portal hypertension

• Megakaryocyte maturation is also reduced leading to fewer platelets
• Platelet aggregation is reduced [Platelets become less sticky]
Both will lead to prolonged bleeding

• Drug metabolism affected
§ Heavy drinking induces liver enzymes and this may increase the metabolism of some drugs
□ More rapid destruction
□ Reduced plasma concentration
□ Lack of effects
40
Q

how can drug metabolism be affected by liver disease

A

§ Reduced drug metabolism [LA, analgesia, sedatives and antibiotics]

○ Warfarin metabolism will be enhanced by regular consumption of 3 units / day
[Some drugs act with alcohol to produce synergistic effects]

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

○ In heavy drinkers, paracetamol can be converted to an intermediate metabolite which is very hepatotoxic
[If a patient does have liver disease / cirrhosis then paracetamol would be the analgesic of choice]

§ Ibuprofen is more likely to cause gastric bleeding = bigger problem

41
Q

what is the disulfiram reaction

A

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

§ Used in patients with an alcohol problem to help them to stop drinking

§ Acetaldehyde builds up and nausea and vomiting occur if alcohol is taken

§ Used in alcohol treatment other drugs cause this reaction
□ Eg metronidazole, cephalosporins, ketoconazole

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

§ Potentially if lots of alcohol is taken it could be fatal
Most people won’t get to this point as being sick and feeling sick is unpleasant and enough to stop a person from drinking

42
Q

what causes GI bleeding in liver disease

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
○ Best to avoid NSAIDs in patients with liver damage

43
Q

should patients with hepatitis C have alcohol

A

no

44
Q

what occurs when alcohol interacts with heroin

A

Sedative effect

Alcohol has a sedative effect too so together just increases this

45
Q

what occurs when alcohol interacts with cocaine

A

○ If 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
○ Can lead to severe arrhythmias

46
Q

what occurs when alcohol interacts with cannabis

A

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

47
Q

what occurs when alcohol interacts with amphetamines

A

Alcohol will increase impairment of judgement

48
Q

what occurs when alcohol interacts with ecstasy

A

Alcohol increases intoxication

But will reduce the potentially fatal fluid retention effect of ecstasy

49
Q

what nutritional problems can occur with alcohol

A

• Alcohol is very calorific
○ 6 pints of beer = 500kcals

• Alcoholics are generally malnourished 
○ General neglect
○ Substitution of food with alcohol [Not enough money to buy both food and alcohol]
○ Deficiencies of 
	§ Thiamine 
		□ Beri-beri
		□ Wernicke's encephalopathy 
	§ Folic acid
		□ Macrocytosis
	§ Vitamin C
		□ Scurvy
50
Q

what 2 risk factors tend to co-exist in oral cancer

A

Smoking and alcohol act synergistically

51
Q

what problems can arise from oral cancer treatment

A

Permanent disfiguration
problems with speech and eating and drinking and socialising
depression drinking

52
Q

what is the treatment for oral caner

A

as the cancer is often advanced at presentation:
• Major surgery: 9-10 hours and radiotherapy
○ Also have chemotherapy

Long and extensive treatment course

53
Q

how does oral cancer occur

A

○ Ethanol metabolite acetaldehyde promotes tobacco initiated tumours

○ Alcohol facilitates absorption of carcinogenic substances across the oral mucosa

○ Damages DNA and alters oncogene production

○ Partly due to thinning of the oral mucosa due to nutritional deficiency [Oral ulceration]

54
Q

what can facial injuries result in

A

Facial injuries can result in psychiatric morbidity
○ PTSD ~ Can lead to self medication with alcohol to try and relieve symptoms
○ Alcohol problems
○ ‘vicious circle’

55
Q

what causes dental trauma

A
  • Broken teeth
  • Lost teeth
  • Damage to soft tissues
  • Lost dentures
  • Interpersonal violence
  • Falls
56
Q

how can non-carious tooth surface loss be caused by alcohol

A

• Alcohol is very acidic

• Gastro-oesophageal reflux disease (GORD)
○ Acid in alcohol directly relaxes the oesophageal sphincter

• Vomiting
○ Regurgitate stomach contents

• Multifactorial
○ Bruxism

• Restoration difficult until problem controlled
○ Need everything to be sorted before you can restore it otherwise there is no point

Restorative nightmare

57
Q

define hazardous drinking

A

Risks for problem are likely

58
Q

define harmful drinking

A

Problems associated with alcohol are actually present

Can be social problems as well as medical and dental issues

59
Q

define dependent drinking

A

Alcohol is needed to function

60
Q

what role do health care professionals have in management of harmful drinking and alcohol dependence

A

The 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

○ As dentists, you should be involved in identifying and helping patients at these levels

○ Not so much at a dependent drinking level as these patients obviously need specialist care and support

61
Q

what is the definition of screening

A
  • The 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 along 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
62
Q

why screen n the healthcare setting

A
  • Alcohol related mortality and morbidity is high

* We looked at some of the morbidity related to alcohol in the previous lecture including its effect on oral health

63
Q

what skills are 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 view of the patient
  • Report writing skills
  • Awareness of services available
  • Recognition of confidentiality issues
64
Q

what are screening tools

A
  • Screening tools are basically questionnaires
  • They are very effective in detecting hazardous drinking and alcohol dependence

• They are short, easily administered and easily scored
○ Don’t take long to do

• They an be used by a wide range of professions

• They can be used opportunistically
○ Short enough so you don’t need specific time / appointment to do these

• Helps to standardise screening so everyone gets the same screening

65
Q

name screening tools

A

• AUDIT
○ Gold standard
○ Slightly long so maybe not used in GDP

• PAT
○ Used in A&E

• FAST
○ Most practical
○ Relevant for GDP setting

• CAGE
○ Not suitable for young people

• POSIT
○ Good but 139 questions
○ Not practical

• CRAFFT
○ Specifically for adolescents

66
Q

explain the ‘cage’ screening tool

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 to eliminate the shakes? [This question helps to identify dependent drinkers]
= CAGE

67
Q

explain the ‘fast’ screening tool

A

• Each question is score 0-4
• Patient is FAST positive if the total score for all questions is ≥ 3
• May only need to ask the first question
Use in GDP

68
Q

explain the ‘audit’ screening tool

A

women:
• 0-6 = Non-hazardous
• 7-13 = Hazardous drinking
• 14-20 women = Harmful drinking

men:
• 0-7 = Non-hazardous
• 8-15 = Hazardous drinking
• 16-19 = Harmful drinking

both:
• >20 possibly dependent drinking (Needs to see someone in specialist alcohol clinical settings)

Some questions very similar to FAST but there are more questions

69
Q

would intervention help hazardous drinkers

A

At risk of developing problems due to alcohol

Amenable to brief intervention

70
Q

would intervention help harmful drinkers

A

Problems due to alcohol are evident

Amenable to brief intervention

71
Q

would intervention help dependent drinkers

A

Displays symptoms of dependence on alcohol

Not amenable to brief intervention

72
Q

what is the teachable moment

A

= a time when people may be more receptive to change
It may be:
• After witnessing someone else being injured [Alcohol involved]
• After experiencing other negative consequences of drinking
• Need to be able to relate the adverse event to drinking
= This is when it becomes teachable

Also called the reachable moment as they are more likely to accept help at this stage

73
Q

when is a brief intervention most effective

A

A brief intervention is most effective if the person receiving it is ready to change
If a person is not ready to change then an intervention will not be successful

74
Q

how can you tell if a person is ready to change

A

use the readiness to change ruler
4 questions thinking about change
patient scores themselves on the ruler on a scaler of 0 (not ready at all) to 10 (very ready)

75
Q

what is the cycle of change

A

These are the steps patients go through when they are making a change:
- contemplative = thinking about it

  • preparation = putting in place strategies to help you make the change
  • action = when you are actually changing
  • maintenance = when you are comfortable with things so you are just trying to maintain your changed behaviour
  • relapse
  • precontemplative = not ready to change
76
Q

what are brief motivational interventions (BMI)

A
  • Behaviour change style of counselling
  • Non-judgemental ~ important
  • Typically lasts between 5 and 20 minutes
  • Suitable as an opportunistic intervention for patients whose main reason for contact is not their drinking behaviour ie dental patients

○ Really about having a conversation
Discussing strategies, offering advice. Never lecturing ~ it is a 2 way conversation

• Patient encouraged to recognise ambivalence between their actual and ideal behaviour and that the responsibility of change rests with them
Need to emphasise responsibility to change lies with them not the dentist

77
Q

what is FRAMES with regards to BMI

A

• Feedback is given to patient about behaviour
Ie telling them how many units is recommended, how many they are having, etc

• Responsibility for change is placed on the patient

• Advice to change is given by practitioner
Give tips for how they might go about having more alcohol free days, how to drink less when they go out, advise having non-alcoholic drinks as well as alcohol when they are out

• Menu of self-directed change options / treatment is offered

• Empathetic style using warmth, respect and understanding
Acknowledge that changing behaviour is difficult

• Self-efficacy is engendered to encourage change
Make them feel that they can do it
They should know you believe they can do it

78
Q

What is 14 units the equivalent of

A
  • 6 pints of beer
  • 6 glasses of wine
  • 14 shots of a spirit
79
Q

what is motivational interviewing

A
  • A conversation about behaviour change
  • Short, Once off situation
  • Non-judgemental

• Motivational
○ Important
○ Should leave the patient feeling motivated and able to change their behaviour using tips and advice given by the dentist

• Aimed at changing behaviour
○ Patient has to do it themselves

BDS3 - PMHP (14 decks)

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