alcohol use and abuse : clinical perspective Flashcards
epidemiology of alcohol abuse
- 3 million deaths a year worldwide
- 7th leading cause of death
- pea incidence age 35-54
- only 18% of those with alcohol dependence receive treatment in the UK, 25% worldwide
- 1.3% prevelance in adult UK population
how long does it take to metabolise 1 unit of alcohol?
1 hour
how is alcohol dependence diagnosed according to the ICD-11?
- disorder of regulation of alcohol use
- repeated or continuous use of alcohol
- strong internal drive to use alcohol
- present for 12 months or 1 month if continuous
- chronically relapsing disorder
- internal drive, compulsion, desire, urge or craving to use alcohol
- impaired control
- prioritisation of alcohol over other activities
- persistent use despite its harms
what does alcohol dow regulate?
GABAa
describe the CAGE alcohol questionnaire
C - have you ever felt you needed to CUT down on your drinking?
A - have people ANNOYED you by criticising your drinking?
G - have you ever felt GUILTY about drinking?
E - have you ever felt you needed a drunk first thing in the morning (EYE-OPENER) to steady your nerves or to get rid of a hangover
2+ requires further questionning
old, not sensitive or specific
what is the gold standard questionnaire for alcohol screening?
- AUDIT screening tool
- FAST version
- an overall total score of 3 or more on the first or all 4 questions is FAST +ve. if positive complete remaining AUDIT alcohol screening questions
what are the 3 main patterns for alcohol dependence/use?
- withdrawal, negative affect
- preoccupation, anticipation
- binge intoxication
describe reward
- ventral and dorsal striatum to basal ganglia
- lack of control from prefrontal cortex
- emotional response — amygdala and hippocampus
describe the addiction as a brain disease model positives and negatives
- disorder of reward systems, impulse control
positives:
- reduce the stigma they experienced by framing their behaviour as a medical vs. moral issue
- could poss reduce fluid, increase insight into drug use, and increase treatment-seeking behaviour
negatives:
- increasing stigma eg. by characterising people as dangerous or out of control
- undermining a client’s sense of personal responsibility
- increasing their sense of helplessness in recovery
what are the UK guidelines for safe drinking?
- 14 units/week
- spread use over 3 days if drinking 14 units week
what is 1 unit of alcohol?
10ml or 8g of pure ethanol
how to calculate units from ABV?
ABV in 1000mls = units
1000mls of 5% beer = 5 units
1000mls of 12% wine = 12 units
what is binge drinking for men and women?
> 8 units for men
6 units for women
how many calories are there in a gram of pure alcohol? vs carbohydrate?
7.1
vs only 4.1 calories in a gram of carbohydrate
what are the potential effects of alcohol on the oesophagus?
- carcinoma of oesophagus, especially squamous carcinoma
- oesophageal varices, associated with chronic liver disease — watch out for Hb drops, raised urea, coffee ground vomit
what are the potential effects of alcohol on the stomach?
- acute gastritis
- acute ulceration
- chronic peptic ulceration
- portal gastropathy
what are the potential effects of alcohol on the pancreas?
- acute pancreatitis
- severe abdominal pain
- radiating to the back
- nausea and vomiting
- greatly elevated serum amylase - chronic pancreatitis (due to chronic inflammation from sustained alcohol use)
- intermittent severe upper abdominal and back pain
- weight loss
- exocrine tissue replaced by fibrosis
- leads to pancreatic malabsorption (steatorrhoea and reduced vitamins A/D/E/K)
- relative preservation of endocrine tissue
what are the mechansims of alcohol related liver disease?
- direct toxic effect
- indirect metabolite effect eg. acetaldehyde (one of the breakdown products of alcohol that builds up)
- activation of free radicals
- induction of enzyme systems esp cytochrome p450
- nutritional deficiencies esp B group vitamins
- liver function impairment
do men or women have a greater risk of alcoholic liver disease? what doubles the risk?
women have a greater risk even at lower amounts
obesity doubles risk
what may be raised in liver disease?
- ALT (alanine transaminase)
- AST (aspartate aminotransferase)
- bilirubin
- gamma GT (gamma-glutamyl transferase)
NOTE! can have extensive liver disease but normal bloods
describe the progression of alcoholic liver disease
- acute fatty change - reversible
- acute alcoholic hepatitis - reversible
- hepatic fibrosis - reversible
- cirrhosis - irreversible
- hepatic decompression - fatal
what are 2 classic signs of liver disease?
jaundice, ascites
what are the potential effects of alcohol on the heart?
- atrial fibrillation
- myocardial infarction
- congestive heart failure - cardiomyopathy
what neuropsychiatric disorders are there in alcohol dependence ?
- seizures
- delirium tremens (DTs)
- Wernicke’s encephalopathy (WE)
- Korsakoff’s psychosis
- polyneuropathy
why do you get seizures in withdrawal and delirium tremens?
- alcohol inhibits NDMA neuroreceptors
- therefore suddenly stopping exposure to alcohol results in the brain going into a state of hyperexcitability dye to the receptors that were being obstructed by alcohol no longer being obstructed
what is delirium tremens?
delirium with hallucinations and autonomic disturbances in alcohol withdrawal
what are Wernicke’s encephalopathy and korsakoff’s psychosis due to?
due to thiamine deficiency and neurotoxic effects of glutamatergic overdrive
both secondary to effects of alcohol and B1 (thiamine) deficiency
describe wernicke’s encephalopathy
- acute
- delirium
- ataxia
- ophthalmoplegia
describe Korsakoff’s psychosis
- chronic (later complication of WE)
- triad of short term memory loss, confabulation and ataxia
what is confabulation?
refers to the production or creation of false or erroneous memories without the intent to deceive, sometimes called “honest lying”
when do seizures and DTs present?
peak seizure incidence 1-2 days after 1st drink
DTs can present late
how do the severity of withdrawal symptoms change with repeated cycles of alcohol intoxication and withdrawal?
what leads to seizure susceptibility?
downregualtion of GABAa receptors and upregulation of NMDA receptors
what medications are given to prevent seizures in alcohol withdrawal?
benzodiazepines such as chlordiazepoxide or diazepam
who are high dose B vitamins given to?
to prevent the damage to neurons due to the excitatory effects of Glu and people deficient in B vitamins (esp thiamine)
what is Acamprosate?
- relapse prevention medication
- works on calcium channels to help reduce the excitatory overdrive, and helps with cravings, anxiety and sleep
what other disorders can you get in alcohol abuse?
- myopathy — typically wasting of proximal muscles in the pelvic girdle - poor mobility
- thrombocytopenia and bleeding
- alcohol is toxic to bone marrow - leads to reduced normal cell levels
- due to effects on the liver leads to folate deficiency and other effects on RBCs
- can progress all the way to pancytopenia
- see low platelets to begin with - so always do clotting as part of treatment (INR and platelets)
the build up of what chemical gives us the horrible hangover effect?
alcohol dehydrogenase
what is disulfiram?
prevents the conversion of acetaldehyde to acetate by aldehyde dehydrogenase
- when taking this medication and you drink, you get flushing, sweating, nausea, tachycardia, palpitations
- aim to put people off from drinking through these adverse effects
- can have cardaic and hepatic effects
safe alcohol advice
units equation
units = (vol (mls) x ABV (%) ) / 1000
CMO guidance - units per week?
14 for men and women
describe the WHO safer alcohol control initiative
