Alcohol Related Disorders Flashcards
how many total symptoms are there in criterion A for AUD
11 possible
how many symptoms do you need out of 11 to meet criterion A for AUD
2+/11
how long must someone have had the symptoms in criterion A for AUD to meet criteria
12+ month period
list the 11 criteria in criterion A for AUD
- using LARGER amounts or LONGER than intended
- persistent desire or failure to CUT DOWN
- spending great deal of TIME in related activities
- intense desire/urge to use drug (CRAVING)
- failure to fulfill major ROLE OBLIGATIONS
- use despite persistent SOCIAL/INTERPERSONAL PROBLEMS
- important activities are GIVEN UP
- use in PHYSICALLY HAZARDOUS situations
- use despite persistent physical/psychological PROBLEMS
- TOLERANCE
- WITHDRAWAL
what is the primary mechanism of action for alcohol
GABA-A receptor positive allosteric modulator
allosteric inhibition of NMDA receptors –> blocks glutamate
how are pleasurable effects of alcohol mediated in the brain
through effects on dopamine neurons in the mesolimbic reward system which connects the VTA to the NA
one is considered one standard drink
0.5 oz of pure EtOH
what is “low risk” drinking standard for women? men?
women–> 10 drinks/week
men–> 15 drinks/week
what is the legal limit for impaired driving
10.6 mmol/L (50mg/dL)
this is reached by 2-3 drinks for men and 1-2 drinks for women
at what EtOH level can you develop coma
above 60mmol.L for non tolerant drinkers and 90-120mmol/L for tolerant drinkers
what is the average elimination rate for alcohol for non-drinkers/social drinkers/heavy drinkers
non drinkers–> 2.6 mmol/L per hour
social drinkers–> 3.3 mmol/L per hour
heavy drinkers –> 4.4 mmol/L per hour
what age group has the highest rate of AUD
18-29
what age group has the lowest rate of AUD
65+
what % of global deaths is due to AUD
3.8%
is AUD more common among men or women
men (12.4% vs 4.9%)
what % of risk variance for AUD is explained by genetics
40-60%
risk for AUD is 3-4x higher among close relatives of person with AUD–> mediated by number of affected relatives, closeness of genetic relationships and severity of alcohol related problems
how much higher is the risk of AUD in children of those with AUD
3-4x higher EVEN IN THOSE WHO ARE ADOPTED
how does impulsivity affect AUD
results in earlier onset, more severe AUD
list risk factors for AUD
preexisting schizophrenia or bipolar disorder
impulsivity (increases risk for all SUD and gambling d/o)
low respose to alcohol
cultural attitudes, availability, personal ezperiences
stress levels
peer substance use
suboptimal coping mechanisms
what is the most common age of onset of AUD
late teens to mid 20s–> majority develop etoh related disorders by late 30s
what predicts earlier onset AUD
pre existing conduct problems
earlier onset of first intoxication
what % of AUD have onset after age 40
10%
*have more severe intoxication and subsequent problems with less consumption
why do those who have onset of AUD after age 40 have more problems
higher brain susceptibility to depressant effects
lower rates of liver metabolism
lower % body water
what is revelant about current intoxication in terms of psych presentation and assessment
EtOH intox = increase rate of suicidal behaviour and completed suicide
what types of cancer are more common in AUD
GI cancer (stomach, esophagus, other)
list how different organ systems are affected by AUD
GI–> gastritis, ulcers, hepatitis; 15% of heavy drinkers have cirrhosis, pancreatitis
CV–> low grade HTN; increased rates of cardiomyopathy, increased TGL, LDL–> increased risk heart disease
peripheral neuropathy
CNS–> direct effects of alcohol, head trauma, vitamin deficiencies, cognitive deficits, degenerative changes in cerebellum, risk of wernicke korsakoffs
which gender may be more vulnerbale to alcohol related liver disease
women
AUD is seen in the MAJORITY of patient with what other diagnoses
conduct + ASPD
*assoc. with early onset and worse prognosis of AUD
–> markedly increased rates in SCZ, bipolar, ASPD
how does AUD affect the immune system
may be immune suppressive–> predispose to infections, cancer
how do you convert from mmol/L to mg/dL
mmol/L x 4.6 = mg/dL
what % of those with high GGT are persistent heavy drinkers
70%
GGT returns to normal with days to weeks of abstinence
what is considered “persistent heavy drinker”
8+ drinker per day
what are two blood tests that may be useful for monitoring abstinence
GGT
CDT (carbohydrate deficient transferrin)
what measure on a CBC is elevated in heavy drinking
MCV–> direct effect of alcohol on erythropoeisis (not as good for monitoring abstinence)
what effects of AUD are seen uniquely in men
decreased testicular size
feminizing effects
list physical signs/symptoms of EtOH withdrawal
nausea
vomiting
gastritis
hematemesis
dry mouth
pufy, blotchy esxpression
mild peripheral edema
list two first line medications for AUD
naltrexone
acamprosate
what % of those treated with acamprosate or naltrexone DO NOT benefit or only partially benefit
30-70%
what two medications are second line for AUD
topiramate (NOT health canada approved)
gapabentin
what other medication (beyond naltrexone, acamprosate, gabapentin, topiramate) may be used for AUD
disulfram–> only for special situations, highly motivated
how long should you treat AUD with medication
6-12 months is the aim
what can help you decide which med to use for AUD
renal/liver function
list 6 considerations that may make you think of inpatient referral for treatment of AUD
- those who have not benefitted from multiple previous tx attempts
- those with co-occurring substance use of MH disorders
- those with concurrent medical conditions
- those in unstable social environment
- pregnant people
- indigenous people–> some inpatient programs offer cultural interventions and tailored programming
what is the mechanism of action of naltrexone
opioid ANTagonist that “takes the pleasure out of drinking”
reduces heavy drinking days
what benefits might someone get from using naltrexone
reduces relapse to heavy drinking (NNT = 11)
improves abstinence (NNT = 20)
can naltrexone be used as PRN
yes if someone is stable
contraindications for naltrexone
avoid in depression
avoid in acute hepatitis/cirrhosis (functional, elevated enzymes are ok but use caution)
concurrent opioid use (is antagonist)
what are the most common side effects of naltrexone
nausea
dizziness
headache
–> mild, subside over time
what should you monitor when Rx naltrexone
LFTs
what is the mechanism of action of acamprosate
glutamate ANTagonist and GABA AGonist
believed to restore imbalance between glutamate-mediated excitation and GABA-mediated inhibition of neural activity, which becomes dysregulated after chronic alcohol consumption
believed to reduce overal neuronal hyperexcitability
reduced chronic withdrawal symptoms
what type of patient may benefit from acamprosate over naltrexone
“withdrawal drinkers” i.e those who drink to avoid withdrawal
acamprosate helps support abstinence in this way
what type of drinker may benefit from naltrexone vs acamprosate
“reward drinkers” i.e those who drink to get drunk00> takes away the reward of drinking
how might someone benefit from acamprosate
fewer heavy drinking days (NNT = ) and better abstinence (NNT = 11)
in which population should you adjust dosing of acamprosate
renal impairment (reduce dose)
what is a contraindication to acamprosate
severe renal impairment (Cr clearance below 30)
in which populations should you use caution with acamprosate
ped, geri
moderate renal impairment
what are the most common side effects of acamprosate
diarrhea
GI pain
nausea
headache
what is the mechanism of action of topiramate
blocks sodium gate ion channels and modulates GABA-A receptors
reduces cravings, rates of relapse in AUD
what is the NNT for topiramate for AUD abstinence
3
contraindication to topiramate use
pregnancy
in which patients should you use topiramate with caution
patients on VPA for seizure disorder
in patients with conditions or on therapies that increase the risk of acidosis (i.e severe resp disorders, renal disease, diarrhea, surgery etc)
sife effects of topiramate
generally well tolerated but some experience severe side effects esp at higher doses
cognitive dulling, parethesia, taste disturbance, anorexia, dizziness
in addition to supporting abstinence in AUD, what other benefits does gabapentin have in AUD
can improve sleep and anxiety in those with AUD
how does gabapentin benefit those with AUD
relapse prevention
reduces alcohol craving, rate of relapse
what is the MOA of gabapentin
GABA-ergic–> pre synaptic modulatior
what are the most common side effects of gabapentin
fatigue
dizziness
peripheral edema
ataxia
list 3 psychosocial interventions that have evidence in AUD
MI
CBT
family therapy
is there any evidence for AA, SMART recovery, peer groups in treatment of AUD
no–> doesnt mean not helpful
what is a screening set of questions for AUD
CAGE questionnaire
C–> every felt the need to Cut down on drinking
A–> ever felt Annoyed at criticism of your drinking
G–> every feel Guilty about your drinking
E–> ever feel the need for a drink first thing in the morning (Eye opener)
men–> 2+ is positive screen; women–> 1+ is positive screen
**may not ID binge drinkers
how many alcohol withdrawal symptoms are listed in the DSM
8
how many symptoms out of the 8 possible are needed to dx alcohol withdrawal per the DSM
2+/8
list the symptoms of alcohol withdrawal in the DSM
- autonomic HYPERactivity
- increased hand tremor
- insomnia
- N/V
- transient hallucination/illusions (visual, auditory, tactile)
- psychomotor agitation
- anxiety
- generalized tonic-clonic seizures
what % of those with AUD have experienced full alcohol withdrawal syndrome
50% of middle class, high functioning people with AUD
80% of those who are hospitalized/homeless with AUD
what % of people who experience alcohol withdrawal syndrome experience seizures/delirium
less than 10%
list risk factors for alcohol withdrawal syndrome
family hx of alcohol withdrawal
personal hx of alcohol withdrawal
concurrent medical conditions
concurrent sedative/hypnotic/anxiolytic drug use
quantity of drinking
frequency of drinking
duration of drinking
when do alcohol withdrawal symptoms usually first appear
6-24 hours after reduction of alcohol intake, following prolonged and heavy use
how long might sleep problems associated with alcohol withdrawal persist
may persist for MONTHS at lower intensities and may contribute to relapse
how many stages of alcohol withdrawal are there?
*not all stages may be experienced
4
when does the first stage of alcohol withdrawal usually occur, and what are the symptoms
12-18 hours after last drink
“the shakes”
tremor
sweating
agitation
anorexia
cramps
diarrhea
sleep disturbance
when does the second stage of alcohol withdrawal usually occur, and what are the symptoms
7-48 hours after last drink
alcohol withdrawal seizures, usually tonic clonic, non focal and brief
when does the third stage of alcohol withdrawal usually occur, and what are the symptoms
around 48 hours after last drink
visual, auditory, tactile hallucinations
when does the fourth stage of alcohol withdrawal usually occur, and what are the symptoms
3-5 days after last drink
DELIRIUM TREMENS
confusion, delusions, hallucinations, agitation, tremors, autonomic hyperactivity (fever, tachy, HTN)
how long after last drink might someone develop alcohol withdrawal seizures
7-48 hours after last drink
how long after last drink might someone develop delirium tremens
3-5 days
how long after last drink might someone develop alcoholic hallucinosis
around 48 hours
what is the mortality of untreated delirium tremens
20-40%
how long does it usually take to recover from delirium tremens
most people. usually are well by 5-7 days since last drink
are DTs reversible?
almost completely in the young
older people may be left with cognitive deficits
what is the “kindling phenomenon” in AUD
idea that with repeated withdrawal episode, the brain is “sensitized” and more likely to be damaged and have seizures with each repeated insult
how do you distinguish alcoholic hallucinosis from DTs
hallucinosis has stable vitals
DTs–> vitals are unstable
what % of those with alcohol withdrawal develop hallucinosis
7-8%
what score can be used to assess risk of severe alcohol withdrawal
(in order to determine if at high or low risk of severe complications to determine whether higher intensity of monitoring is needed)
PAWSS score–> 4+/10 points is high risk
*93% sensitivity, 99% specificity
what are the 10 questions on the PAWSS score for risk of alcohol withdrawal severity
- intoxicated in last 30 days?
- previous alcohol rehab tx?
- any previous withdrawal?
- previous blackouts?
- previous alcohol withdrawal seizures?
- previous DTs?
- use of alcohol with other substances in last 90 days?
- use of alcohol with benzos/barbituates in last 90 days?
- BAC above 200mg/dL or 43mM?
- any increased autonomic activity? (i.e HR above 120, sweats, agitation, nausea)
list areas of assessment in CIWA-A
physical–> N/V, tremor, agitation, paroxysmal sweats, HA/fullness in head
psych/cog–> anxiety, orientation/clouding of sensorium
perceptual–> tactile disturbances, auditory disturbances, visual disturbances
if you are managing alcohol withdrawal in the community, what types of meds are preferred
non-benzos i.e gabapentin, clonidine, carbamazepine
how do you treat acute withdrawal
if severe alcohol withdrawal, hx DTs, seizures etc–> regular benzos may be needed i.e ativan 2mg q4h then 1mg (if liver concerns) or diazepam (if renal concerns)
–> likely longer hospital stays and overuse of benzos if use regular rather than PRN with CIWA
is there universal guidelines for thiamine in alcohol withdrawal
no
what is the generally used guidelines for thiamine in alcohol withdrawal
IV for minimum of 5 days
how do you dose thiamine for wernickes encephalopathy
500mg IV TID x 3-5 days then 250mg IV x 3-5 days then 100mg PO TID
when might you consider clonidine for alcohol withdrawal management
if high BP/HR, autonomically activated
can suppress persistent noradrenergic symptoms such as anxiety, HTN, tachy that do not resovle w benzos or anticonvulsants
does not prevent seizures or DTs
what is a good benzo sparing agent for alcohol withdrawal management
gabapentin 600mg TID
can use in isolation of PAWSS 3 or less
what is the maximum score on CIWA
67
what is considered “mild” on CIWA
less than 10
what is considered “severe” on CIWA
above 20
after what score on CIWA should you start alcohol withdrawal treatment
above 10
*consult with physician and consider ICU for those who score above 35
how should you treat someone in alcohol withdrawal if they have history of withdrawal seizures
diazepam 20mg po q1h for minimum of 3 doses regardless of subsequent CIWA scores
*or lorazepam if elderly or liver probs
what should you use to manage alcoholic hallucinosis in alcohol withdrawal
haloperidol 2-5mg q1-4h–> max 5 doses per day or use atypical antipyschotics
diazepam for seizure prophylaxis
when should you admit someone in alcohol withdrawal to hospital
still in withdrawal after 80mg of diazepam
DTs, recurrent arrhythmias or multiple seizures
medically ill or unsafe to d/c home
what other medication other than diazepam can be used for seizure prophylaxis in alcohol withdrawal
magnesium sulfate 5g IV x 3 days
when should you consider VPA tx in alcohol withdrawal
if comorbid bipolarity or mood dysregulation i.e BPD
why should you use benzos in acute alcohol withdrawal?
REDUCES MORTALITY in acute alcohol withdrawal
