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13. Substance Use + Addictions > Alcohol Related Disorders > Flashcards

Alcohol Related Disorders Flashcards

1
Q

how many total symptoms are there in criterion A for AUD

A

11 possible

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2
Q

how many symptoms do you need out of 11 to meet criterion A for AUD

A

2+/11

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3
Q

how long must someone have had the symptoms in criterion A for AUD to meet criteria

A

12+ month period

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4
Q

list the 11 criteria in criterion A for AUD

A
  1. using LARGER amounts or LONGER than intended
  2. persistent desire or failure to CUT DOWN
  3. spending great deal of TIME in related activities
  4. intense desire/urge to use drug (CRAVING)
  5. failure to fulfill major ROLE OBLIGATIONS
  6. use despite persistent SOCIAL/INTERPERSONAL PROBLEMS
  7. important activities are GIVEN UP
  8. use in PHYSICALLY HAZARDOUS situations
  9. use despite persistent physical/psychological PROBLEMS
  10. TOLERANCE
  11. WITHDRAWAL
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5
Q

what is the primary mechanism of action for alcohol

A

GABA-A receptor positive allosteric modulator

allosteric inhibition of NMDA receptors –> blocks glutamate

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6
Q

how are pleasurable effects of alcohol mediated in the brain

A

through effects on dopamine neurons in the mesolimbic reward system which connects the VTA to the NA

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7
Q

one is considered one standard drink

A

0.5 oz of pure EtOH

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8
Q

what is “low risk” drinking standard for women? men?

A

women–> 10 drinks/week

men–> 15 drinks/week

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9
Q

what is the legal limit for impaired driving

A

10.6 mmol/L (50mg/dL)

this is reached by 2-3 drinks for men and 1-2 drinks for women

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10
Q

at what EtOH level can you develop coma

A

above 60mmol.L for non tolerant drinkers and 90-120mmol/L for tolerant drinkers

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11
Q

what is the average elimination rate for alcohol for non-drinkers/social drinkers/heavy drinkers

A

non drinkers–> 2.6 mmol/L per hour

social drinkers–> 3.3 mmol/L per hour

heavy drinkers –> 4.4 mmol/L per hour

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12
Q

what age group has the highest rate of AUD

A

18-29

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13
Q

what age group has the lowest rate of AUD

A

65+

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14
Q

what % of global deaths is due to AUD

A

3.8%

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15
Q

is AUD more common among men or women

A

men (12.4% vs 4.9%)

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16
Q

what % of risk variance for AUD is explained by genetics

A

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

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17
Q

how much higher is the risk of AUD in children of those with AUD

A

3-4x higher EVEN IN THOSE WHO ARE ADOPTED

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18
Q

how does impulsivity affect AUD

A

results in earlier onset, more severe AUD

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19
Q

list risk factors for AUD

A

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

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20
Q

what is the most common age of onset of AUD

A

late teens to mid 20s–> majority develop etoh related disorders by late 30s

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21
Q

what predicts earlier onset AUD

A

pre existing conduct problems

earlier onset of first intoxication

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22
Q

what % of AUD have onset after age 40

A

10%

*have more severe intoxication and subsequent problems with less consumption

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23
Q

why do those who have onset of AUD after age 40 have more problems

A

higher brain susceptibility to depressant effects

lower rates of liver metabolism

lower % body water

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24
Q

what is revelant about current intoxication in terms of psych presentation and assessment

A

EtOH intox = increase rate of suicidal behaviour and completed suicide

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25
Q

what types of cancer are more common in AUD

A

GI cancer (stomach, esophagus, other)

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26
Q

list how different organ systems are affected by AUD

A

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

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27
Q

which gender may be more vulnerbale to alcohol related liver disease

A

women

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28
Q

AUD is seen in the MAJORITY of patient with what other diagnoses

A

conduct + ASPD

*assoc. with early onset and worse prognosis of AUD

–> markedly increased rates in SCZ, bipolar, ASPD

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29
Q

how does AUD affect the immune system

A

may be immune suppressive–> predispose to infections, cancer

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30
Q

how do you convert from mmol/L to mg/dL

A

mmol/L x 4.6 = mg/dL

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31
Q

what % of those with high GGT are persistent heavy drinkers

A

70%

GGT returns to normal with days to weeks of abstinence

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32
Q

what is considered “persistent heavy drinker”

A

8+ drinker per day

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33
Q

what are two blood tests that may be useful for monitoring abstinence

A

GGT

CDT (carbohydrate deficient transferrin)

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34
Q

what measure on a CBC is elevated in heavy drinking

A

MCV–> direct effect of alcohol on erythropoeisis (not as good for monitoring abstinence)

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35
Q

what effects of AUD are seen uniquely in men

A

decreased testicular size

feminizing effects

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36
Q

list physical signs/symptoms of EtOH withdrawal

A

nausea
vomiting
gastritis
hematemesis
dry mouth
pufy, blotchy esxpression
mild peripheral edema

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37
Q

list two first line medications for AUD

A

naltrexone

acamprosate

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38
Q

what % of those treated with acamprosate or naltrexone DO NOT benefit or only partially benefit

A

30-70%

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39
Q

what two medications are second line for AUD

A

topiramate (NOT health canada approved)

gapabentin

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40
Q

what other medication (beyond naltrexone, acamprosate, gabapentin, topiramate) may be used for AUD

A

disulfram–> only for special situations, highly motivated

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41
Q

how long should you treat AUD with medication

A

6-12 months is the aim

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42
Q

what can help you decide which med to use for AUD

A

renal/liver function

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43
Q

list 6 considerations that may make you think of inpatient referral for treatment of AUD

A
  1. those who have not benefitted from multiple previous tx attempts
  2. those with co-occurring substance use of MH disorders
  3. those with concurrent medical conditions
  4. those in unstable social environment
  5. pregnant people
  6. indigenous people–> some inpatient programs offer cultural interventions and tailored programming
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44
Q

what is the mechanism of action of naltrexone

A

opioid ANTagonist that “takes the pleasure out of drinking”

reduces heavy drinking days

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45
Q

what benefits might someone get from using naltrexone

A

reduces relapse to heavy drinking (NNT = 11)

improves abstinence (NNT = 20)

46
Q

can naltrexone be used as PRN

A

yes if someone is stable

47
Q

contraindications for naltrexone

A

avoid in depression

avoid in acute hepatitis/cirrhosis (functional, elevated enzymes are ok but use caution)

concurrent opioid use (is antagonist)

48
Q

what are the most common side effects of naltrexone

A

nausea

dizziness

headache

–> mild, subside over time

49
Q

what should you monitor when Rx naltrexone

A

LFTs

50
Q

what is the mechanism of action of acamprosate

A

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

51
Q

what type of patient may benefit from acamprosate over naltrexone

A

“withdrawal drinkers” i.e those who drink to avoid withdrawal

acamprosate helps support abstinence in this way

52
Q

what type of drinker may benefit from naltrexone vs acamprosate

A

“reward drinkers” i.e those who drink to get drunk00> takes away the reward of drinking

53
Q

how might someone benefit from acamprosate

A

fewer heavy drinking days (NNT = ) and better abstinence (NNT = 11)

54
Q

in which population should you adjust dosing of acamprosate

A

renal impairment (reduce dose)

55
Q

what is a contraindication to acamprosate

A

severe renal impairment (Cr clearance below 30)

56
Q

in which populations should you use caution with acamprosate

A

ped, geri

moderate renal impairment

57
Q

what are the most common side effects of acamprosate

A

diarrhea

GI pain

nausea

headache

58
Q

what is the mechanism of action of topiramate

A

blocks sodium gate ion channels and modulates GABA-A receptors

reduces cravings, rates of relapse in AUD

59
Q

what is the NNT for topiramate for AUD abstinence

A

3

60
Q

contraindication to topiramate use

A

pregnancy

61
Q

in which patients should you use topiramate with caution

A

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)

62
Q

sife effects of topiramate

A

generally well tolerated but some experience severe side effects esp at higher doses

cognitive dulling, parethesia, taste disturbance, anorexia, dizziness

63
Q

in addition to supporting abstinence in AUD, what other benefits does gabapentin have in AUD

A

can improve sleep and anxiety in those with AUD

64
Q

how does gabapentin benefit those with AUD

A

relapse prevention

reduces alcohol craving, rate of relapse

65
Q

what is the MOA of gabapentin

A

GABA-ergic–> pre synaptic modulatior

66
Q

what are the most common side effects of gabapentin

A

fatigue

dizziness

peripheral edema

ataxia

67
Q

list 3 psychosocial interventions that have evidence in AUD

A

MI

CBT

family therapy

68
Q

is there any evidence for AA, SMART recovery, peer groups in treatment of AUD

A

no–> doesnt mean not helpful

69
Q

what is a screening set of questions for AUD

A

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

70
Q

how many alcohol withdrawal symptoms are listed in the DSM

A

8

71
Q

how many symptoms out of the 8 possible are needed to dx alcohol withdrawal per the DSM

A

2+/8

72
Q

list the symptoms of alcohol withdrawal in the DSM

A
  1. autonomic HYPERactivity
  2. increased hand tremor
  3. insomnia
  4. N/V
  5. transient hallucination/illusions (visual, auditory, tactile)
  6. psychomotor agitation
  7. anxiety
  8. generalized tonic-clonic seizures
73
Q

what % of those with AUD have experienced full alcohol withdrawal syndrome

A

50% of middle class, high functioning people with AUD

80% of those who are hospitalized/homeless with AUD

74
Q

what % of people who experience alcohol withdrawal syndrome experience seizures/delirium

A

less than 10%

75
Q

list risk factors for alcohol withdrawal syndrome

A

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

76
Q

when do alcohol withdrawal symptoms usually first appear

A

6-24 hours after reduction of alcohol intake, following prolonged and heavy use

77
Q

how long might sleep problems associated with alcohol withdrawal persist

A

may persist for MONTHS at lower intensities and may contribute to relapse

78
Q

how many stages of alcohol withdrawal are there?

A

*not all stages may be experienced

4

79
Q

when does the first stage of alcohol withdrawal usually occur, and what are the symptoms

A

12-18 hours after last drink

“the shakes”

tremor

sweating

agitation

anorexia

cramps

diarrhea

sleep disturbance

80
Q

when does the second stage of alcohol withdrawal usually occur, and what are the symptoms

A

7-48 hours after last drink

alcohol withdrawal seizures, usually tonic clonic, non focal and brief

81
Q

when does the third stage of alcohol withdrawal usually occur, and what are the symptoms

A

around 48 hours after last drink

visual, auditory, tactile hallucinations

82
Q

when does the fourth stage of alcohol withdrawal usually occur, and what are the symptoms

A

3-5 days after last drink

DELIRIUM TREMENS

confusion, delusions, hallucinations, agitation, tremors, autonomic hyperactivity (fever, tachy, HTN)

83
Q

how long after last drink might someone develop alcohol withdrawal seizures

A

7-48 hours after last drink

84
Q

how long after last drink might someone develop delirium tremens

A

3-5 days

85
Q

how long after last drink might someone develop alcoholic hallucinosis

A

around 48 hours

86
Q

what is the mortality of untreated delirium tremens

A

20-40%

87
Q

how long does it usually take to recover from delirium tremens

A

most people. usually are well by 5-7 days since last drink

88
Q

are DTs reversible?

A

almost completely in the young

older people may be left with cognitive deficits

89
Q

what is the “kindling phenomenon” in AUD

A

idea that with repeated withdrawal episode, the brain is “sensitized” and more likely to be damaged and have seizures with each repeated insult

90
Q

how do you distinguish alcoholic hallucinosis from DTs

A

hallucinosis has stable vitals

DTs–> vitals are unstable

91
Q

what % of those with alcohol withdrawal develop hallucinosis

A

7-8%

92
Q

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)

A

PAWSS score–> 4+/10 points is high risk

*93% sensitivity, 99% specificity

93
Q

what are the 10 questions on the PAWSS score for risk of alcohol withdrawal severity

A
  1. intoxicated in last 30 days?
  2. previous alcohol rehab tx?
  3. any previous withdrawal?
  4. previous blackouts?
  5. previous alcohol withdrawal seizures?
  6. previous DTs?
  7. use of alcohol with other substances in last 90 days?
  8. use of alcohol with benzos/barbituates in last 90 days?
  9. BAC above 200mg/dL or 43mM?
  10. any increased autonomic activity? (i.e HR above 120, sweats, agitation, nausea)
94
Q

list areas of assessment in CIWA-A

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

95
Q

if you are managing alcohol withdrawal in the community, what types of meds are preferred

A

non-benzos i.e gabapentin, clonidine, carbamazepine

96
Q

how do you treat acute withdrawal

A

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

97
Q

is there universal guidelines for thiamine in alcohol withdrawal

A

no

98
Q

what is the generally used guidelines for thiamine in alcohol withdrawal

A

IV for minimum of 5 days

99
Q

how do you dose thiamine for wernickes encephalopathy

A

500mg IV TID x 3-5 days then 250mg IV x 3-5 days then 100mg PO TID

100
Q

when might you consider clonidine for alcohol withdrawal management

A

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

101
Q

what is a good benzo sparing agent for alcohol withdrawal management

A

gabapentin 600mg TID

can use in isolation of PAWSS 3 or less

102
Q

what is the maximum score on CIWA

A

67

103
Q

what is considered “mild” on CIWA

A

less than 10

104
Q

what is considered “severe” on CIWA

A

above 20

105
Q

after what score on CIWA should you start alcohol withdrawal treatment

A

above 10

*consult with physician and consider ICU for those who score above 35

106
Q

how should you treat someone in alcohol withdrawal if they have history of withdrawal seizures

A

diazepam 20mg po q1h for minimum of 3 doses regardless of subsequent CIWA scores

*or lorazepam if elderly or liver probs

107
Q

what should you use to manage alcoholic hallucinosis in alcohol withdrawal

A

haloperidol 2-5mg q1-4h–> max 5 doses per day or use atypical antipyschotics

diazepam for seizure prophylaxis

108
Q

when should you admit someone in alcohol withdrawal to hospital

A

still in withdrawal after 80mg of diazepam

DTs, recurrent arrhythmias or multiple seizures

medically ill or unsafe to d/c home

109
Q

what other medication other than diazepam can be used for seizure prophylaxis in alcohol withdrawal

A

magnesium sulfate 5g IV x 3 days

110
Q

when should you consider VPA tx in alcohol withdrawal

A

if comorbid bipolarity or mood dysregulation i.e BPD

111
Q

why should you use benzos in acute alcohol withdrawal?

A

REDUCES MORTALITY in acute alcohol withdrawal

13. Substance Use + Addictions (13 decks)

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