Alcohol and substance abuse Flashcards
What are the specific types of disorder?
Acute intoxication Harmful use Dependence syndrome Withdrawal state Withdrawal state with delirium Psychotic disorder Amnestic disorder other mental and behavioural disorders (e.g dementia)
What is the definition of harmful use?
The continuation of substance use despite evidence of damage to the user’s physical or mental health or to their social, occupational or familial well-being. The damage may be denied or minimised by the individual concerned.
What is dependence syndrome?
Primacy: The drug and need to obtain it becomes the most important things in the person’s life taking priority over all other responsibilities
Continued use despite negative consequences
Loss of control of consumption
Narrowing of the repertoire: The user moves from using a range of psychoactive substances to a single drug taken in preference to all others.
Rapid reinstatement of dependent use after abstinence: when the user relapses to drug use after a period of abstinence they are at risk of rapidly returning to the pattern of dependent use in a much shorter period of time.
Tolerance and withdrawal
What is the epidemiology of alcohol misuse?
Approximately 93% of men and 87% of women in the UK drink alcohol
More than 9 million people in England regularly drink more than the recommended daily limits
Younger people tend to drink more heavily (exceeding 8 units for men and 6 units for women) on a single occasion than older people
Older people tend to drink more frequently than younger people
What are the ill-health and mortality statistics associated with alcohol?
It is estimated that approximately 9% of UK adult men and 4% of UK adult women are dependent on alcohol
65% of hospital admissions due to alcohol related diseases, injuries and conditions are men
In 2013 there were 6,592 alcohol-related deaths. This is a 10% increase compared to 2003 (5,984)
The most common cause of alcohol-related death is alcoholic liver disease
Alcoholic liver disease is one of the few major causes of premature mortality that is increasing
What are the biological, psychological and occupational/social risk factors for alcohol misuse?
First degree relatives of alcohol-dependent persons have around seven times the risk of developing alcohol problems themselves
Genetic factors for metabolism fo alcohol
Mental illness
Positive/negative reinforcement
Socioeconomic background
Price of alcohol
Social isolation/loss of spouse
What are the medical complications of alcohol misuse?
CNS:
Cognitive and memory impairment
Reduction in brain weight and volume
Wernicke-Korsakoff Syndrome
Central pontine myelinolysis (pseudobulbar palsy and quadriplegia)
Cerebellar degeneration
PNS:
Alcoholic peripheral neuropathy and myopathy
Optic atrophy and visual changes
Respiratory:
Increased susceptibility to infections and aspiration pneumonia
Cardiovascular:
Alcoholic cardiomyopathy
Arrhythmias (especially atrial fibrillation)
Hypertension
Cerebrovascular events (especially haemorrhagic strokes)
Hepatic:
Cirrhosis, fatty liver, hepatocellular carcinoma
Pancreas:
Pancreatitis, DM, malabsorption
Renal:
Hepato-renal syndrome, hypertension, CKD
Spleen:
Splenomegaly secondary to hepatic cirrhosis and portal hypertension
Small and large intestine:
Malabsorption, chronic diarrhoea, lower GI carcinoma
Gastro-oesophageal:
Mallory-Weiss tears secondary to vomiting
Oesophageal varices +/- haemorrhage
Barretts oesophagus and oesophageal carcinoma
Gastritis and gastric erosions
Peptic ulcer disease +/- haemorrhage
Gastric carcinoma
Female sexual health:
Fertility problems, foetal alcohol syndrome
Male sexual health:
Erectile dysfunction
Hypogonadism in men
Haematological:
Microcytic anaemia, neutropenia, thrombocytopenia
What os alcoholic hallucinosis?
substance-induced psychotic illness which is a rare complication of prolonged heavy alcohol use. The individual experiences hallucinations (usually auditory) in clear consciousness while sober. The auditory hallucinations may begin as “elemental hallucinations” such as banging or murmuring sounds but, with ongoing alcohol use, progress to formed voices.
Usually resolves after cessation of alcohol use
What is alcohol related brain damage (ARBD)?
Recognised in the diagnostic classification system ICD-10
60% of chronic heavy drinkers will display some degree of cognitive impairment on cognitive testing while sober.
impairment of short-term memory, long-term recall, new skill acquisition, executive functioning, but with relative preservation of IQ and language skills.
CT/MRI brain imaging in heavy drinkers reveals cortical and subcortical atrophy with prominent white matter loss.
The direct neurotoxic effects of are exacerbated further by thiamine deficiency which can lead to Wernicke-Korsakoff syndrome
What is pathological jealousy ?
monosymptomatic delusional disorder seen most commonly secondary to current or previous heavy alcohol misuse. The individual presents with the primary delusion that his partner or spouse has or is being unfaithful.
The patient may go to great lengths to obtain “evidence” of the infidelity e.g. following their partner to work, examining the partner’s clothing.
There is a significant association with violence and even homicide towards the supposedly unfaithful partner.
What are other psychiatric comorbidities associated with alcohol use?
Anxiety and depressive disorders
Suicide: Studies have indicated that the lifetime risk of suicide for dependent drinkers is as high as 10-15%
Schizophrenia
What are the social complications of alcohol misuse?
Marital disharmony and divorce Domestic violence Missing work or poor performance Financial problems Risky sexual activity Psychological harm to family members Increased risk of crime Homelessness
What occurs with different levels of alcohol consumption?
Low - enhanced sense of well-being, greater confidence, relief of anxiety, disinhibition, talkative, flirtacious
Medium - inappropriate sexual/aggressive behaviour, labile mood, overdramatic, suicidal behaviour
High - incoordination, slurred speech, ataxia, amnesia
Very High - unconsciousness, respiratory depression, coma, death
What are the risk factors for severe withdrawal?
Other medical illness - eg pneumonia/UTI
Advanced cirrhosis
Previous withdrawal episodes
When should alcohol withdrawal syndrome be anticipated and prophylactically treated?
Known alcohol dependence
PMH alcohol withdrawal
Consumed >10 units alcohol >10 days
Current withdrawal symptoms
What are withdrawal seizures?
5-15% of withdraws cases are complicated by grand-cal seizures
Occur 6-48 hours after last drink
Risk factors: Prolonged alcohol consumption, PMH, epilepsy, head injury
What is mild alcohol withdrawal?
4-12 hours after last drink Coarse tremor Sweating Insomnia Tachycardia N+V Psychomotor agitation Mood disturbance - anxiety, depression, feeling edgy Transient hallucinations - tactile/visual Hyperacusis Intense CRAVING for alcohol Lasts around 2-5 days
What is delirium tremens?
Acute confusional state, occurs in severe AWS
Medical emergency, in 5%
1-7 days after last drink
Clouding of consciousness, disorientated to time, place and person
Amnesia for recent events
Hallucinations - visual/tactile/auditory (lilliputian)
Paranoid delusions
Severe psychomotor agitation and tremor
Fever
Autonomic disturbances - heavy sweating, raised pulse and BP, fever
Electrolyte imbalance
5-15% mortality if treated or 40% mortality if untreated due to cardiovascular, hyper/hypothermia, infection
What are the predisposing factors for delirium tremens?
physical illness, eg hepatitis, pancreatitis, pneumonia
Differential Diagnoses = alternative cause of delirium, head injury, Wernicke encephalopathy
What is the management for delirium tremens?
Benzodiazepines for symptomatic relief
Reducing regime - start with 80mg and slowly reduce
Reduce symptoms and risk of seizures
Chlordiazepine is usually used- lower abuse potential than diazepam
Nutritional and vitamin supplements
Thiamine- pabrinex, 2 ampules, twice daily for 5 days
Monitoring for hypothermia, dehydration, hypoglycaemia, hypokalemia, hypomagnesaemia
Psychosocial follow up care
What is Wernicke-Korsakoff syndrome?
Occurs due tot thiamine deficiency leads to neuronal degeneration
What is Wernicke’s encephalopathy?
Thiamine deficiency due to:
Poor dietary habits, reduced thiamine absorption form GI, liver disease reduces hepatic storage of thiamine
Symptoms:
Acute confusional state
Nystagmus Opthalmoplegia - paralysis of eye muscles
Ataxic gait
Peripheral neuropathy
Resting tachycardia
Due to haemorrhages and secondary gliosis in periventricular and periaqueductal grey matter -especially involving the mammillary bodies, hypothalamus and tegmentum of midbrain
What is the management for Wernicke’s?
Parental vitamin replacement
Give IV pabrinex
Do NOT rehydrate with glucose before given thiamine
Treat AWS
If untreated, 80% lead to Korsakoff syndrome 15% mortality if untreated
What is Korsakoff syndrome?
Due to thiamine deficiency, head injury, encephalitic processes and CO poisoning
Anterograde amnesia - impairment in the ability to lay down new memories
Retrograde amnesia
Confabulation - making up false stories to fill gaps created by amnesia
Apathy - lose interest in things quickly, appear indifferent to change
What is the management for Korsakoff syndrome?
Treat WE if present
Continue oral thiamine and vitamins for up to 2 years
Psychosocial interventions for cognitive impairment
20% of cases show complete recovery 25% show significant recovery
What are other alcohol related disorders?
Alcohol induced dementia syndrome - cortical atrophy and ventricular enlargement Alcohol induced psychotic disorder Alcohol induced mood disorder Alcohol induced anxiety disorder Sleep disorders Sexual dysfunction
What are the screening tools used for assessment of alcohol misuse?
CAGE: - CUT DOWN? - ANNOYED at criticising drinking - GUILTY about drinking - EYE OPENING - drink in the morning to settle nerves FAST - fast alcohol screening test
What should be included in the history for alcohol abuse?
Lifetime pattern of alcohol consumption: age of first drink, changes in drinking habit Current alcohol consumption Signs of dependence Social/occupational problems Previous treatment attempts Physical and mental health
What physical examinations should be carried out in alcohol abuse?
Examination of major systems and general condition
Symptoms of withdrawal syndrome
Excessive capillarisation of facial skin and conjunctivae
Stigmata of liver disease
Cerebellar signs
Peripheral neuropathy
What are the investigations for alcohol abuse?
MCV - HIGH specificity, remains raised for 3-6 months after abstinence
- GGT (20-90% sensitivity) - more specific than other LFTs for alcohol-related liver
inflammation
- Liver US if indicated
- Blood alcohol concentration / breath alcohol
