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Psychiatry > Alcohol Misuse and Dependence > Flashcards

Alcohol Misuse and Dependence Flashcards

1
Q

What is alcohol dependence characterised by?

A

Craving, tolerance, a preoccupation with alcohol and continued drinking in spite of harmful consequences e.g. liver disease or depression.

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2
Q

What Liver diseases can be caused by alcohol dependence?

A
  • Alcoholic Fatty Liver Disease
  • Cirrhosis
  • Alcoholic Hepatitis
  • Liver Failure
  • Hepatic carcinoma
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3
Q

What are complications and diseases of the CNS caused by alcohol misuse and dependence?

A
  • Poor memory/cognition
  • Cortical/cerebellar atrophy/degeneration
  • Subdural haemorrhage
  • Seizures
  • Falls
  • Neuropathy
  • Wernicke’s and Korsakoff Syndrome
  • Acute intoxication with loss of consciousness
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4
Q

What are complications and diseases of the GI tract caused by alcohol misuse and dependence?

A
  • D&V
  • Peptic ulcer
  • Erosions
  • Varices
  • Pancreatitis
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5
Q

What are complications and diseases of the CVS caused by alcohol misuse and dependence?

A
  • Arrhythmias e.g. AF
  • HTN
  • Cardiomyopathy with HF
  • Strokes
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6
Q

What are complications and diseases of MSK caused by alcohol misuse and dependence?

A

• Heavy drinking disrupts calcium metabolism, so increased osteoporosis risk

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7
Q

What are complications and diseases of the sperm caused by alcohol misuse and dependence?

A

• Decreased fertility, decreased sperm mobility & LOSS OF LIBIDO

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8
Q

What are ‘Other’ complications and diseases caused by alcohol misuse and dependence?

A
  • Malignancy  most common GI and breast
  • Decreased haemoglobin and increased MCV
  • Violent crime
  • Depression and suicide
  • Anxiety
  • Alcohol dependence syndrome
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9
Q

What is the ICD10 definition of ‘Dependence syndrome’?

A

repeated substance use and that typically include a strong desire to take the drug, difficulties in controlling its use, persisting in its use despite harmful consequences, a higher priority given to drug use than to other activities and obligations, increased tolerance, and sometimes a physical withdrawal state.

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10
Q

What is meant by ‘harmful use’?

A

A pattern of psychoactive substance use that is causing damage to health. The damage may be physical (as in cases of hepatitis from the self-administration of injected psychoactive substances) or mental (e.g. episodes of depressive disorder secondary to heavy consumption of alcohol).

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11
Q

What 4 things is alcohol dependence strongly associated with?

A
  • Increased criminal activity
  • Increased domestic violence
  • Increased rate of significant mental health problems
  • Increased rate of significant physical health problems
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12
Q

What percentage of adults in Britain are deemed as ‘hazardous drinkers’?

A

26%

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13
Q

What is the definition of Alcohol Abuse?

A

Repeated drinking that harms a person’s work and social life

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14
Q

What is implied by alcohol addiction?

A
  • Increased tolerance to alcohol
  • Narrowing of drinking repertoire
  • Difficulty or failure of abstinence
  • Withdrawal: sweats, nausea or tremor
  • Person’s priority is to maintain alcohol intake
  • Often aware of their compulsion to drink
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15
Q

What assessment tools are used for assessing alcohol dependence?

A
  • AUDIT questionnaire
  • SADQ
  • CAGE questions
  • History taking
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16
Q

What is the AUDIT questionnaire?

A

o More detailed than CAGE
o ‘Alcohol Use Disorders Identification Test’
o Out of 40
o Can be shortened to AUDIT-C which is out of 12 but if person scores 3+ then the full version should be completed.

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17
Q

What is SADQ?

A

o Severity of Alcohol Dependence Questionnaire
o Mild dependence <15 score (these people usually do not need assistance with alcohol withdrawal)
o Moderate is between 15-30 (usually need assisted alcohol withdrawal but can be managed in the community if no other risks)
o Severe is 30+ (these people will need assisted alcohol withdrawal, typically in the inpatient or residential setting)
o Do it when a person scores 15 or more on AUDIT

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18
Q

What are the CAGE questions?

A

o Cut down? - ever felt the need
o Angry? – when someone told you, you should cut down
o Guilt? – for drinking
o Eye-opener? – ever needed to have a drink in morning i.e. to stop shakes

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19
Q

What questions would you ask specifically to determine alcohol dependence during the history?

A

o Gradual deterioration in functioning?
o What alcohol dependence has done to work, social, family, relationships
o Do they drink alone or with others? – what circumstances
o What is the most they have ever drunk? And how recent was this?
o Do they have any illnesses related to their alcohol intake? (physical and psychiatric)

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20
Q

What examination features may be present in those with alcohol dependence/misuse?

A
  • General demeanour  ethanolic or hepatic fetor
  • Malnourishment
  • Signs of acute withdrawal e.g. coarse tremor and tachycardia
  • Signs of liver disease  palmar erythema, gynaecomastia, ascites, spider naevi, jaundice
  • Hepatomegaly
  • Ascites
  • Gonadal atrophy
  • AF
  • Cardiomyopathy
  • Wernicke-Korsakoff syndrome (ataxia, confusion, ophthalmoplegia, amnesia, peripheral neuropathy, dementia)
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21
Q

What blood alcohol level indicates extreme intoxication?

A

> 300mg/100ml

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22
Q

What blood alcohol level may indicate possible fatality?

A

> 400mg/100ml

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23
Q

How may extreme intoxication of alcohol present?

A

Drowsiness and then coma

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24
Q

What other blood tests except blood alcohol level would be requested in someone with alcohol misuse/dependence?

A

o FBC – suspect excessive alcohol when MCV is raised and
o Platelet count may be decreased
o LFTs – elevated liver enzymes/deranged LFTs. Gamma-GT is the best indicator of excessive alcohol consumption
o Clotting screen
o U&Es
o May see dyslipidaemia and hypertriglyceridaemia with chronic alcohol consumption
o Check fasting glucose (chronic pancreatitis can lead to diabetes mellitus)

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25
Q

What is an important factor when deciding on management of alcohol dependence?

A

Whether the patient is wanting to change and cut down/abstain from their drinking

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26
Q

What non-pharmacological management is available for those with alcohol dependence/Misuse?

A
  • Advice on dangers of excessive or binge drinking
  • Providing advice leaflets on availability of any local organisations
  • Trying to decipher the reasons/factors for the patient drinking and how these could be avoided
  • Agreeing objectives with the patient that can be accomplished e.g. controlled drinking (weaker drinks, spacing drinks, alternating alcoholic with non-alcoholic drinks, eating with drinks)
  • CBT
  • Social network or environment-based therapies
  • Self-help/support groups e.g. AA
  • Refer to specialist
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27
Q

What two pharmacological pathways would be used for management of alcohol dependence/misuse?

A

Detoxification

Relapse prevention

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28
Q

What are the symptoms of alcoholic dementia?

A

problems with memory, intelligence, personality, language, reading and writing

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29
Q

How is alcoholic dementia caused?

A

• It is caused by chronic and regular alcohol intake causing the atrophy of the cerebrum and cerebellum that may be irreversible but can stop progressing with abstinence from alcohol and may also improve

30
Q

How does alcohol damage the brain?

A

Alcohol poisons the nerve cells within the brain. Drinking alcohol can also cause people to get thiamine deficiency as they do not eat properly and so do not get all their required vitamins. Alcohol can also affect the blood supply to the brain which also contributes to atrophy and degeneration. When the frontal lobe is affected, it can also cause personality changes.

31
Q

Why is thiamine important within the CNS?

A

It is involved in the production of myelin sheaths

32
Q

What occurs when there is reduced intake of thiamine?

A

Demyelination, which can lead to peripheral neuropathy. (usually starts in the peripheries and works upwards as thiamine becomes less and less readily available).

33
Q

When is detoxification usually offered?

A

This is usually for people who drink >15 units a day and/or those who score 20+ on an AUDIT questionnaire.

34
Q

Where does detoxification usually take place?

A

Can be either in community or inpatient setting

35
Q

When is an inpatient setting more suited/required?

A
  • Previous seizures or DT with alcohol withdrawal or severe withdrawal reactions
  • Risk of patient committing suicide
  • Those without social support
  • Previous attempts/detoxes to stop alcohol use which have failed
  • Physical illness caused by alcohol or any other significant medical conditions
  • Under age of 16
  • Tried community and didn’t work
36
Q

What is required for community detoxification?

A
  • Daily supervision to detect complications early e.g. DTs, continuous vomiting, deterioration in mental state
  • Multivitamin preparations to prevent Wernicke’s encephalopathy
  • Benzodiazepines to prevent withdrawal symptoms (usually CHLORDIAZEPOXIDE)
  • Continuing support -primary health care team, community alcohol team, residential rehabilitation programmes, voluntary organisations mental health team
37
Q

After a detox, what level of drinking is advised?

A

Abstinence is recommended following detox from clear alcohol dependence and/or marked physical damage. It is best if abstinence is practised long-term but some patients may return to controlled drinking after a period of abstinence.

38
Q

What medications are used for detoxification?

A
  • Benzodiazepines - most commonly use = Chlordiazepoxide (long acting)
  • short acting Benzes
  • Bitamin B complexes
  • Beta Blockers
39
Q

what are long-acting benzodiazepines used for?

A

used to reduce tremor and agitation also help modulate GABA response in the brain

40
Q

What are examples of long-acting Benzodiazepines?

A

Chlordiazepoxide*

Diazepam

41
Q

What are short-acting benzodiazepines used for in detox?

A

For Tx of seizures or if the patient has liver impairment

42
Q

What is the most commonly used short-acting benzodiazepine?

A

IV Lorazepam

43
Q

Why are short-acting benzodiazepines better for those with liver impairment?

A

As it has a shorter half-life

44
Q

What is the risk of using a short-acting benzodiazepines?

A

May experience more extreme withdrawal symptoms

45
Q

Why are vitamin B complexes prescribed during detoxification?

A

to prevent wernickes encephalopathy

46
Q

How is the vitamin B complex prescribed?

A

IV Pabrinex

47
Q

When are beta-blockers given in alcohol detox?

A

Only if Benzos are insufficient at reducing autonomic hyperactivity

48
Q

What is the common plan for detoxification?

A
  • High dose medication the first day that alcohol is stopped (Benzo)
  • Gradually reduce the dose over the next 5-7 days
  • No alcohol is to be consumed during the detoxification
  • Usually see someone everyday to check and support
  • Suggest that a person abstains from alcohol for a year after detox to prevent relapse
49
Q

What Medications may be prescribed to help with abstinence or prevention of relapse after alcohol detox?

A 
Acamprosate
Naltrexone
Disulfram
Nalmefene
Baclofen
50
Q

How does Acamprosate help with alcohol abstinence and prevention of relapse?

A
  • Blocks GABA and reduces NDMA(N-methyl-D-aspartate) receptor glutamate-related excitation
  • Has a possible neuroprotective role in detoxification
  • Does not interact with alcohol
  • Reduces alcohol cravings
  • Often given post-detox to maintain stabilisation
51
Q

How does Naltrexone help with alcohol abstinence and prevention of relapse?

A
  • Is a competitive antagonist of the opioid receptor (which alcohol also acts on in order to cause pleasure as it releases endogenous opioids) and prevents these endogenous opioids from being released. So, means that there is a reduction in the pleasure effects of alcohol (therefore a deterrent to alcohol) ‘removes buzz’.
  • Associated with a lower relapse rate, fewer drinking days and longer length of abstinence.
  • Used commonly in patients who are binge drinkers
52
Q

How does Disulfram help with alcohol abstinence and prevention of relapse?

A
  • Means that you get a nasty reaction if you drink alcohol, there is even a possibility of death if alcohol is consumed whilst taking this medication
  • Can be used if acamprosate or naltrexone are not suitable for patient
  • Be aware that reactions may occur if there are even small amounts of alcohol in perfume, ‘non-alcohol’ beers, etc.
53
Q

How does Nalmefene help with alcohol abstinence and prevention of relapse?

A
  • Used to reduce alcohol consumption in those with dependence
  • Should be prescribed with adjunctive psychological support
54
Q

How does baclofen help with alcohol abstinence and prevention of relapse?

A
  • Low quality of evidence

* Can reduce alcohol craving and intake

55
Q

What non-pharmacological treatment can help with abstaining rom alcohol or preventing relapses?

A
  • CBT
  • Self-help groups or support groups e.g. AA
  • Social support
56
Q

How many patients suffering from significant alcohol withdrawal experience an alcohol withdrawal seizure?

A

up to 1/3

57
Q

When does acute alcohol withdrawal usually occur?

A

6-48 hours after last drink

58
Q

What are the complications and diseases associated with alcohol withdrawal?

A
  • Uncomfortable withdrawal symptoms e.g. continuous vomiting, pains
  • Delirium Tremens
  • WKS
  • Seizures
  • Depression
  • Polysubstance abuse
  • Electrolyte disturbances
59
Q

What is the pathophysiology of alcohol withdrawal?

A

Alcohol increases GABA and dopamine. When alcohol is abstained from for a period of time and get into a withdrawal state, there is loss of stimulation at the GABA-A receptor, tis causes a reduction in chloride flux. This is associated with: tremors, diaphoresis, tachycardia, anxiety and seizures.

60
Q

When do symptoms usually peak?

A

Day 2 of alcohol withdrwal

61
Q

When do symptoms usually present?

A

around 8 hours after a significant fall in blood alcohol levels

62
Q

What symptoms may be experienced with minor withdrawal?

A
  • Insomnia
  • Fatigues
  • Tremor
  • Mild anxiety
  • Nausea and vomiting
  • Headache
  • Excessive sweating
  • Palpitations
  • Anorexia
  • Depression
  • Alcohol craving
63
Q

What symptoms may be experienced with more severe alcohol withdrawal and when may they occur?

A

• Alcoholic hallucinosis - includes visual, auditory or tactile hallucinations (can occur 12-24 hours after alcohol intake)
• Withdrawal seizures - are generalise tonic-clonic and usually occur 24-48 hours after alcohol intake has stopped
DELIRIUM TREMENS -important to look out for signs of this, this may occur 48-72 hours post alcohol abstinence.

64
Q

What is important to ask in a history when someone presents with alcohol withdrawal?

A
  • Quantity of alcohol intake and duration of alcohol use
  • Time since the last alcoholic drink
  • Whether they have had another other alcohol withdrawals, whether these were successful for any period of time
  • Severity of any past alcohol withdrawals if applicable.
  • Medical history including psychiatric and look out for alcohol induced illnesses e.g. liver disease.
  • Drug history (incl. OTC, herbal and illicit drug use as well as prescription and allergies)
  • Support network  important for detoxification process.
65
Q

Other than wanting to cut down on alcohol, what else may precipitate an episode of alcohol withdrawal?

A

illness or problems with alcohol availability - may not have actually wanted to cut down

66
Q

What medications are given for alcohol withdrawal?

A
  • Benzodiazepines (chlordiazepoxide)

- Thiamine (IV pabrinex inpatient, oral thiamine/vit B supplements outpatient)

67
Q

When does delirium tremens usually occur?

A

48 - 96 hours after last drink (or reduction in intake) - peak at 72 hours

68
Q

What follow-up is required after detoxification and acute alcohol withdrawal?

A
  • Close follow up needed in order to prevent relapse
  • Medication to prevent relapse can be given e.g. Acamprosate, Naltrexone, Disulfiram, Nalmefene (see Detox notes for more info.)
  • Counselling self-help groups e.g. AA
  • Address other co-existing medical and psychological problems
69
Q

When is the peak incidence of seizures following alcohol withdrawal?

A

36 hours

70
Q

When is the peak incidence of symptoms following alcohol withdrawal?

A

6-12 hours

Psychiatry (40 decks)

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