Alcohol Misuse

Question 1

How are units of alcohol calculated?

Answer 1

(volume)(% of alcohol)/10

Question 2

What does higher risk drinking mean?

Answer 2

drinking 35units of alcohol weekly

Question 3

What does increased risk drinking mean?

Answer 3

drinkign 15-35 units of alcohol weekly

Question 4

What are the UK guidelines for low risk drinking?

Answer 4

no more than 14units of alcohol weekly (spread over 3 days/more)

Question 5

What is alcohol dependence syndrome?

Answer 5

• Strong desire to consume alcohol
• difficulty in controlling consumption
• withdrawal state & tolerance
• neglect of interests/pleasures due to alcohol use
• Persistence of use despite harmful effects

Question 6

Which range of tools are available to screen alcohol misuse?

Answer 6

• AUDIT (hazardous drinking)
• CAGE (alcohol abuse & dependence)
• TACE {T-tolerance}
• TWEAK (in pregnancy) {W-worried}
• MAST (full version in psych)
• PAT (for A&E)
• FAST (for A&E)

Question 7

What investigations are available to screen for alcohol use

Answer 7

• GGT (liver damage)
• carbohydrate deficient transferrin-identifies drinking 5/more units a day for 2 weeks/more
• mean corpuscular volume (alcohol is most common cause of raised MCV)

Question 8

What specialists interventions are available?

Answer 8

detoxification-pt becomes alcohol free
relapse prevention-psychosocial and pharmacological interventions aimed at maintaining abstinence following detoxification

Question 9

How does alcohol affect the excitatory NMDA

receptors?

Answer 9

Alcohol inhibits the action of excitatory NMDA ion channels which leads to upregulation of receptors in chronic use

Question 10

How does alcohol affect inhibitory GABA receptors?

Answer 10

it stimulates the inhibitory GABA-A ion channels which leads to downregulation of receptors in chronic use.

Question 11

What is the overall effect of alcohol withdrawal (loss of inhibition of NMDA ion channels and loss of stimulation of GABA-A ion channels)?

Answer 11

Excess of glutamate activity (lead to seizures & delirium) and reduced GABA inhibition (lead to tremors, diaphoresis, tachycardia & seizures). Excess glutamate is toxic to nerve cells leading to CNS excitability and toxicity

Question 12

When does alcohol withdrawal symptoms begin

Answer 12

first symptoms occurs within hours of abstinence and peaks at 24-48h

Question 13

What are symptoms of alcohol withdrawal syndrome?

Answer 13

tremors, restlessness, anxiety, N+V, LOA, insomnia

Question 14

What are the signs of alcohol withdrawal syndrome?

Answer 14

tachycardia, systolic hypertension

Question 15

What other complications may occur from alcohol withdrawal syndrome?

Answer 15

• generalised seizures
• delirium tremens (usually 3 days into withdrawal and presents as confusion & sympathetic overdrive which can lead to cardiovascular collapse)

Question 16

How long does alcohol withdrawal syndrome usually last?

Answer 16

5-7 days

Question 17

What are the symptoms of delirium tremens?

Answer 17

• confusion/disorientation
• fever
• hypertension
• hallucinations (visual & auditory)
• paranoid ideation

Question 18

What is the management for alcohol withdrawal syndrome?

Answer 18

1. benzodiazepines
   - acts on GABA-A receptors
   - Use longer acting agents ie diazepam & chlordiazepoxide
   - Titrate against severity of syndrome and reduce gradually over 7 days/more
2. vitamin supplementation
   - parenteral thiamine (prevent wernicke’s encephalopathy)
   - increase dose if wernicke’s suspected

Question 19

What other supportive management can be carried out?

Answer 19

• adequate hydration
• anti-emetic
• analgesia
• treat intercurrent infections

Question 20

What can be done for relapse prevention?

Answer 20

• Disulfiram (antabuse)
• Acamprosate
• Naltrexone (first line agent for relapse prevention)

Question 21

What is the mechanism of action of disulfiram

Answer 21

• inhibits metabolism of alcohol
• inhibits acetaldehyde dehydrogenase which leads to accumulation of acetaldehyde when it interacts with alcohol
• this causes the symptoms of a “hangover” to occur almost immediately

Question 22

What happens when disulfiram is taken with alcohol?

Answer 22

• flushed skin
• tachycardia
• n&v
• arrhythmias
• hypotension

Question 23

What is the mechanism of action of acamprosate?

Answer 23

• acts centrally on glutamate and GABA systems
• reduces cravings with modest treatment effect
• start as soon as detoxification is complete
• continue through relapses
• *side effects
• headache
• diarrhea and nausea

Question 24

What is the mechanism of action of naltrexone?

Answer 24

opioid antagonist and reduces reward from alcohol