ALCOHOL DEPENDENCE

Question 1

what is alcohol

Answer 1

a by-product of the fermentation of various fruits and grains - drinking alcohol is a common widely accepted activity in most countries and cultures

fat and water soluble, readily diffuses across all cell membranes, peak blood levels are within 30-60min

Question 2

blood alcohol concentration (BAC)

Answer 2

grams of alcohol in 100ml of blood

> 0.15% = significant impairment of balance, slurred speech, nausea, vomiting

> 0.30% = loss of consciousness, anaesthesia

Question 3

easiest way to measure alcohol

Answer 3

measure alcohol through expired through respiration - breathalyzer (estimates BAC by analysing a sample of the breath which contains alcohol passed from bloodstream into the lungs)

Question 4

alcohol’s moa

Answer 4

agonist effect on GABA receptor - increasing binding or influx of Cl- (CNS depressant)

GABA synapses control activity of different neuronal systems - glutamate, dopamine, opioids

many ‘neuropsychiatric effects’

Question 5

chronic consequences of alcohol

Answer 5

• peripheral neuropathy and dementia caused by alcohol toxicity and vit B6 (thiamine) deficiency
• sleep disturbance, depression or anxiety
• overall malnourishment

Question 6

alcohol effect on thiamine

Answer 6

• alcohol prevents conversion of thiamine to TPP in small intestine and interferes with its storage in the liver

Question 7

how genetic variation impacts alcohol

Answer 7

(far east population) have an inactive form of aldehyde dehydrogenase - acetaldehyde is not further converted into acetic acid - so small amounts of alcohol result in toxic levels of acetaldehyde which cause nausea, vomiting, sweating and severe headache

Question 8

how gender impacts alcohol metabolism

Answer 8

females have less alcohol dehydrogenase and metabolise 50% less than men

women have greater fat-to-muscle ratio - so less blood for proportional body weight, so have greater blood concentration in women then men

Question 9

risks from alcohol

Answer 9

accidental injury
sexual misdemeanours
violence
CV disease
liver diseases
cancers

Question 10

when is drinking alcohol considered a ‘problem’

Answer 10

once dependent on alcohol for day-to-day functioning - AUDIT (alcohol use disorder identification test) or CAGE questions

Question 11

IBA (alcohol identification and brief advice)

Answer 11

a process of identifying people who maybe have alcohol issues via a structured conversation about alcohol consumption

Question 12

brief intervention (not appropriate for dependency) - FRAMES

Answer 12

Feedback > patients personal risk or impairment
Responsibility > emphasise personal responsibility for change
Advice > suggest how to cut down/abstain
Menu > offer alternative options
Empathetic > listen reflectively, explore reasons for change
Self efficacy > enhance the pts belief in their ability to change

Question 13

SADQ (severity of alcohol dependence questionnaire) is a 20 item questionnaire - scoring system

Answer 13

answers rated on a 4-point scale: never (0), sometimes (1), often (2), nearly always (4)

> 31 indicates severe alcohol dependence

16-30 indicates moderate dependence

<16 only a mild physical dependence

Question 14

tests required for alcohol dependence

Answer 14

complete blood count (reduced vitamin B12 and folate levels can be red flags)

LFTs (AST/ALT >1.5)

Question 15

management of alcohol withdrawal

Answer 15

• abrupt cessation can lead to withdrawal symptoms - BZs given to manage either by ‘symptom triggered approach’ or ‘fixed-dose regimen’
• delirium tremens is a serious withdrawal effect with high mortality - a type of agitated delirium approx. 72 hours after last drink
• need adequate fluid and nutritional replacement (parenteral thiamine or vit B with ascorbic acid Pabrinex IM)

Question 16

CDP in treating alcohol withdrawal

Answer 16

chlordiazepoxide used long-acting, prescribed on a reducing dosage regimen over 5-7 days

starting dose based on symptom severity

Question 16

treatment of alcohol withdrawal

Answer 16

• use BZs due to similarity in moa with alcohol (GABA mediated)
• BZs diminish the severity of the symptoms as neuronal systems begin to revert back to pre-alcohol states
• diazepam most common

Question 16

drugs that reduce cravings to support abstinence

Answer 16

acamprosate
disulfiram
naltrexone
nalmefene

BUT also high placebo effect if engaging with any health professional and joining support groups (AA)

Question 17

disulfiram moa

Answer 17

• irreversibly inhibits aldehyde dehydrogenase causing accumulation of acetaldehyde - sweating, nausea, facial flushing, tachycardia, hypotension

Question 18

disulfiram monitoring and dose

Answer 18

• intensity to reaction is dose-dependent (loading dose of 400-800mg) followed by 100-200mg maintenance
• start 24 hours after last drink
• monitor every 2 weeks for 1st 2 months, then monthly
• liquid or tablets - supervised 2 or 3 times weekly as enzyme inhibition is irreversible and clinical effect lasts 7-10 days

Question 19

acamprosate moa

Answer 19

• GABA A agonist and glutamate (NMDA) antagonist - reduces craving
• 7 days to reach therapeutic levels so can start immediately after detox
• side effects: diarrhoea, abdominal pain, nausea, pruritis

Question 20

acamprosate dose and monitoring

Answer 20

• daily dose is 1998mg (666mg tds) for >60kgs
• usually over 6 months treatment
• determine renal and hepatic function prior to use

Question 21

nalmefene moa

Answer 21

opioid antagonist (mu and delta receptors AND a partial agonist at kappa receptors)

side effects: nausea, vomiting, sweating

Question 22

nalmefene dose

Answer 22

as required use i.e. 18mg tablet taken 1-2 hours before exposure to alcohol

Question 23

naltrexone moa

Answer 23

non-selective opioid antagonist

side effects: nausea, headache, abdominal pain

Question 24

naltrexone dose

Answer 24

start at 50mg daily - usually for 6 months duration

hepatoxicity at high dose

avoid opioid analgesia

Question 25

drug of choice when co-morbid with schizophrenia

Answer 25

naltrexone or acamprosate preferred

Question 26

signs and symptoms of FAS

Answer 26

• low body weight
• poor coordination
• hyperactive behaviour
• difficulty with attention
• poor memory
• difficulty in school (esp. maths)
• learning disabilities
• speech and language delays