Vertrees Alcohol Flashcards
Alcohol Disorders drinking stats
Everybody drinks! ( ? )
86% of adults have had a drink at some point
70% in the past year
55% in the past month
Almost 50% have had 0-1 drinks in last month
Nearly 50% of all alcohol is consumed by only 10% of adults – 24M adults
30% of American adults don’t drink at all
nother 30 percent consume less than one drink per week
alcohol and fatalities
Alcohol involved in about 55% of auto fatalities
40% of homicides are linked to alcohol
- Most often with ASPD having severe use disorder
88,000 persons die annually from related medical illnesses
30,000 alcohol related drinking deaths annually
- Disinhibition, sadness and irritability escalates suicide risk
How much alcohol is in a drink?
10gr to 14gr ETOH per drink (varying sources)
this equates to 1.5oz of liquor, a 12 oz
beer or 4oz of wine.
Blood Alcohol Level (BAL) is usually measured in mg/dL.
1 drink produces a BAL of about 25mg/dL in men and 40-50mg/dL in women
alcoholic beverages
Ethyl alcohol primarily found in alcoholic beverages, OTC) medications i.e. cough syrups, as an aerosol, and topicals.
Alcoholic beverages are primarily water and ethyl alcohol.
alcohol metabolism
Alcohol metabolism occurs in the body with the assistance of two enzymes:
Alcohol Dehydrogenase (ADH)
Aldehyde Dehydrogenase (AldDH)
ADH can process alcohol at about 1 drink per hour
Alcohol dehydrogenase {ADH} (found in large amounts in liver) reduces alcohol to acetaldehyde.
Aldehyde dehydrogenase {AldDH} is required to convert the acetaldehyde to acetic acid.
Acetic acid, once introduced into the normal metabolic pathway, becomes carbon dioxide and water.
Pharmacokinetics:
. Orally absorbed rapidly
B. Peak BAL in about 30min, but longer with food
C. Small intestine is the primary site of
absorption, with distribution in total body
water.
D. Due to fat stores, and therefore, smaller
total body water distribution, BAL is higher
in females compared to males.
Alcohol Use Disorder Criteria
Two of the following in 12 months:
Alcohol taken in larger amounts or longer period than initially intended
Persistent desire or unsuccessful efforts to cut down or control use
A lot of time devoted to getting, using, and recovering it
Cravings, or urges to use
Recurrent use leading to failures in major roles
Continued use despite having persistent/recurrent social problems from use
Important activities given up or reduced due to use
Recurrent use in physically hazardous situations
Continued use despite knowing its causing problems
Tolerance
Withdrawal
Alcohol Intoxication Criteria
Recent alcohol ingestion
Significant problematic behaviors during or shortly after use:
Inappropriate sexual or aggressive behavior
Mood lability
Impaired judgment
One or more, during or shortly after use
- Slurred speech
- Incoordination
- Unsteady gait
- Nystagmus
- Impairment in attention or memory
- Stupor or coma
Associated with Intoxication
Amnesia (blackouts)
- Likely due to rate at which high BAL is reached
Mood disturbance
- With initial rising BAL often get bright, talkative, expansive
- As time progresses, especially if BAL starts falling, mood often shifts to depressed, withdrawn, and cognitive impairment
CNS Effects of Blood Alcohol Level
A. BAL 50-100 mg/dL (non tolerant person)
Sedation
Subjective sensation of “high”
Reaction times are slowed (lengthened)
Can occur with 2 to 4 drinks in a short period of time.
80 mg/dL is legally drunk in many states (.08)
B. BAL of 100 – 200 mg/dL (non tolerant)
Impaired speech – slurring, repetitive
Impaired motor function – finger to nose test
Clumbsiness, gait disturbance, ataxia – can’t tandem walk or tip toe walk
Increasingly disinhibited
Blackouts are common with anterograde amnesia prominent
Disruption of sleep pattern with a primary reduction in REM sleep
Relaxation of the muscles of the pharynx increases the likelihood of snoring and sleep apnea
C. BAL of 200 – 300 mg/dL (non tolerant)
Emesis
Stupor
D. BAL of 300 – 400 mg/dL (non tolerant)
Coma
E. BAC of 500 mg/dL (non tolerant person)
Respiratory depression
Death
Typical presentation in Alcohol poisoning in
non-tolerant individuals such as college
fraternity hazing rituals, teenage drinking etc
Acute Alcohol Intoxication – Management
Treat/prevent respiratory depression
Monitor/prevent aspiration
Give Thiamine – 100mg oral or IM
Monitor labs – may need to correct electrolyte imbalance, and if hypoglycemic, give thiamine first to reduce risk of developing Wernicke’s encephalopathy due to lactic acidosis
Chronic Alcoholism – Management
Multi-system disease is common
Do Vital Signs
Monitor labs – BAL, CBC, LFT, Basic Chem
Cover the patient with vitamins, thiamine and a benzodiazepine if needed to prevent withdrawal symptoms – a long acting benzodiazepine is best (clorazepate dipotassium or diazepam)
Repeat the Vital Signs – watch for deterioration
Chronic Alcoholism – Effects
A. Liver
1. Alcoholic cirrhosis occurs in about 25%
of heavy drinkers
2. Women more susceptible than men
3. If concurrent Hepatitis C is present, the
effects on the liver are more severe
B. Gastrointestinal
Pancreatitis occurs 3x rate of normals and
10% of all cases of pancreatitis occur in
chronic alcoholics.
Chronic gastritis and diarrhea
Vitamin deficiency due to malabsorption
Weight loss in many cases
C. CNS Effects / Neurotoxicity
- Peripheral neuropathy in 15%, usually start as distal paresthisias in hands and feet
- Cerebellar degeneration in 1%, starting
with gait and balance deterioration
- Wernicke’s encephalopathy – state of
confusion due to thiamine deficiency
- Korsakoff’s Psychosis – longstanding memory
problems and chronic confabulation occur
Other Effects
Cancer occurs at a rate 10x that of nondrinkers
Cardiovascular effects:
20-30% of hypertension in males
50% risk of hypertension at 3-4 drinks/day
Nearly 100% risk of HTN at 6-7 drinks per day
Withdrawal Criteria
Cessation of prolonged and heavy alcohol use
Leading to 2 or more (below) in hours to few days
- Autonomic hyperactivity (diaphoresis or HR >100)
- Increased tremor
- Insomnia
- Nausea or vomiting
- Transient hallucinations (visual, tactile or auditory)
- Psychomotor agitation
- Anxiety
- Generalized tonic-clonic seizures
Alcohol Withdrawal Syndromes
Uncomplicated alcohol withdrawal – the “shakes”. -
Occurs 12 to 18 hrs after cessation of drinking and peaks at 24 to 48 hr. Can subside without treatment in 5-7 days
Alcohol withdrawal seizures – occur 7 to 48 hr after cessation of drinking and peak at 24 to 48 hrs. Status epilepticus is rare.
Alcoholic Hallucinosis
- Auditory (most likely), visual or tactile hallucinations that begin within 48 hrs of cessation of drinking.
- No confusion or disorientation
may last up to 7 days.
Alcohol withdrawal delerium (delerium tremens)
- usually begin 2-3 days after cessation of drinking, with symptoms peaking 4-5 days later.
- Sxms: disorientation, agitation, hallucinations, autonomic instability
Alcohol Withdrawal Syndromes – management
Long acting benzodiazepines (diazepam, chlordiazepoxide, clorazepate dipotassium)
In severe liver disease or elderly, shorter acting benzodiazepines like lorazepam or oxazepam are preferred
Thiamine 50-100mg oral or IM once and folic acid 1mg orally daily
Haloperidol or risperidone for hallucinosis
Screening – The CAGE test
Have you tried to CUT DOWN your drinking?
Have you felt ANNOYED by questions about your drinking?
Have you felt GUILTY about your drinking?
Have you ever needed an EYE OPENER in the morning?
Lab Screening
BAL
Helpful in assessing tolerance cross-sectionally
GGT (gamma-glutamyltransferase)
70% of persons with elevated GGT consume 8+ drinks daily
CDT (carbohydrate-deficient transferrin)
Similar use to GGT
MCV
Elevated in chronic use but has long half life
AST/ALT
Treatment options
AA, Al-Anon, Community Support programs Structured Detox programs Inpatient Alcohol treatment – short or long term Physician support Motivational Interviewing Family support and interventions Professional coercion
medication options
Antabuse (disulfiram) –inhibits aldehyde dehydrogenase which leads to accumulation of acetaldehyde causing nausea, vomiting, hypotension and palpitations
Naltrexone – mu-opioid antagonist – reduces the pleasurable effects and craving for alcohol
Campral (acamprosate)- reduces craving for alcohol via glutamate receptor modulation. It also reduces the physical & emotional discomfort in alcohol cessation
Prognosis
Studies seem to show wide abstinence ranges
Relapse is part of recovery.
Helpful to think of “success” in terms of harm reduction
Tobacco-Related Disorders stats
About 21% of the American public smokes
- 22% are former smokers
- Initiation almost always happens by 21
Nearly 80% of persons with a Severe Mental Illness smoke
Nicotine is the major psychoactive substance in tobacco
Nicotine is very stimulating and half life is only 2 hours
- the need to continue to use is high which leads to addictive power
Nicotine effects:
Increase in heart rate Increase in blood pressure Increase in respiratory rate Dizziness, lightheadedness Tremor Nausea
Tobacco Withdrawal Criteria
Daily use of tobacco for several weeks Abrupt cessation or reduction leading to 4 or more: - Irritability, anger, frustration - Anxiety - Difficulty concentrating - Restlessness - Increased appetite - Depressed mood - Insomnia
Other Tobacco Cessation Sxms
Typically Heart rate decreases by 5-12 bpm
Weight increase of 4-7 lbs in the first year
Note: Tobacco compounds increase metabolism of many psychiatric medications
Tobacco-Related Disorders-
Other factors
A. Reduction in smoker’s rights
B. Taxation by state governments
C. Shifting of public opinion
D. Increased awareness of health issues
Tobacco related Health issues
A. Lung disease – COPD, Asthma, Cancer
B. Cardiovascular disease – myocardial
infarction, peripheral vascular disease,
stroke
C. Headaches
D. Impotence in males
E. Perinatal Low birth weight and miscarriage
Smoking is leading cause of morbidity and mortality (from NIDA)
400,000 deaths per year in the US
Worst consequences are associated with tar
Pleasurable, reinforcing effects are from nicotine
Tobacco-Related Disorders- Treatment options
A. Nicotine Replacement Therapy
- Nicotine transdermal patches - Nicotine gum - Nicotine lozenges - Nicotine inhaler - E-cigs? - No data to show they help in getting off nicotine (NIDA)
B. Acupuncture
C. Hypnosis
D. Bupropion (Zyban, Wellbutrin, others)
- effective in 30% with nothing else
E. Varenicline (Chantix) – effective in up to
44%
Combination therapy is best for success
Tobacco quitting success?
Often defined as tobacco-free
- Not nicotine-free
Most smokers make many attempts at quitting
- At 6 weeks rates can be in the 40-50% range
- By one year 5-10% are tobacco free
about 50% will achieve sustained remission
- Rare to quit before 30
