Week 3 - F - Alcohol misuse - Dependance, Alcohol withdrawal, delirium tremens, prevention of relapse, , Wernicke's&Korsakoffs

Question 1

10% of the drinking population drink half of all the alcohol drunk. Age of first drink falling to 12 and 14. Highest rates of drinking in adolescence and early twenties How do you calculate the units of alcohol in a drink?

Answer 1

Look at the volume of alcohol - eg 750 ml bottle of wine

Look at the percentage of alcohol in the drink eg 12% bottle of wine

Units = Volume in litres x % alcohol = 0.75 x 12 = 9 units alcohol

Question 2

For the concepts of the risks of drinking, it has been defined as high, increased and low risk drinking What is high risk drinking?

Answer 2

High risk drinking is where you regularly consume over 35 units of alcohol per week

Question 3

What is increased risk drinking? What is low risk drinking?

Answer 3

Increased risk drinking - this is where you regularly consume between 15 and 35 units of alcohol per week

Low risk drinking is where you meet the guidelines for both men and women where less than 14 units of alcohol is consumed on a weekly basis - this should be spread out over three day s

Question 4

What is harmful use of alcohol?

Answer 4

This is a pattern of psychoactive substance misuse that is cause damage to health - be it physical or mental health

Question 5

What is alcohol dependence syndrome criteria? (this is the same as the ICD-10 criteria for dependence)

Answer 5

There is a strong desire or sense of compulsion to take the drug

There is difficulty in controlling substance use - onset, termination or level of use

There is a physiological withdrawal state

Evidence of tolerance

Persistence of neglect of other pleasures / interests/ others despite clear evidence of harmful consequences

Question 6

There is a range of tools available for the screening of alcohol dependency syndrome What is the acronym that s used to diagnose abuse and dependence?

Answer 6

CAGE!

Cut down - have you ever considered drinking less

Annoyed - have you ever been annoyed at somebody bringing up the amount that you drink

Guilty - have you ever felt guilty at the amount that you dirnk

Eye opener - have you ever had an experience where you thought, wow i need to stop - eg drinking when you get out of bed

Question 7

Laboratory tests are not useful in screening for alcohol related problems May have a role in monitoring response to treatment. What can be measured as an indication for liver injury? What i the carbhydrate deficient transferrin and when can this be measured?

Answer 7

As an indication of liver injury - an measure GGT - gamma glutamyl transferase

Carbohydrate deficient transferin- this identifies men who drink great than 5 units per day for two weeks

Question 8

What happens to the mean cell volume (mean corpuscular volume MCV) in patients who have alcohol dependency?

Answer 8

Mean corpuscular volume- alcoholism is the most common cause of raised MCV.

Question 9

Brief interventions target audience : adults who have been identified via screening as drinking a hazardous or harmful amount of alcohol. Attending NHS or NHS-commissioned services or services offered by other public institutes. How long should brief interventions work and what is the acronym used for these interventions?

Answer 9

These brief interventions last 5-15 minutes

The acronym used is FRAMES

Question 10

What does FRAMES stand for?

Answer 10

F-feedback p review the problems experienced because of alcohol

R-responsibility - its the patients responsibility to change

A-advice - advise reduction or abstinence

Menu - provide options for changing behaviours

E - empathy - use an empathetic approach

S-self efficacy - encourage optimism about changing behaviour

Question 11

When should you consider referral for specialist treatment in alcohol abuse?

Answer 11

Consider if they show moderate or severe levels of alcohol dependence Or

Have failed to benefit from structured, brief advice and

Only refer to a specialist if they wish to tackle the issue- this is important

Show signs of severe alcohol-related impairment or co-morbid condition

Question 12

What is detoxification? What is relapse prevention?

Answer 12

Detoxification is the process by which the patient becomes alcohol free

Relapse prevention - a combination of pshycosocial and pharmacological interventions aimed at maintaining abstinence or problem free drinking without detoxification

Question 13

What ion channels does alcohol effect in the body?

Answer 13

It effects the NDMA-glutamate ion controlled channels and it effects the GABA type A ion controlled channels

Question 14

What effects does alcohol and its chronic effects have on the NMDA-glutamate controlled ion channels and the GABA type A controlled ion channels?

Answer 14

Alcohol inhibits the NMDA-glutamate controlled ion channels, chronic use leads to upregulatin of the receptors

Alcohol potentiates the effects of GABA-type A controlled ion channels - chronic use leads to deregulation of the GABA channels

Question 15

After speaking of upregulation of NDMA glutamate controlled ion channels and deregualtion of GABAtype A controlled ion channels, what happens when there is alcohol withdrawal?

Answer 15

When a patients present with alcohol withdrawal, there is a massive increase in glutamate activity due to the upregulation of the receptors and There is a massive decrease in GABA activity due to the deregulation of the receptors

Question 16

What effect does excess glutamate have on the nerve cells?

Answer 16

Excess glutamate activity is toxic to the nerve cells.

Withdrawal of alcohol too quickly leads to CNS excitability and neurotoxicity.

Question 17

How does alcohol withdrawal syndrome present?

Answer 17

There is restlessness, tremor, anxiety, nausea, loss of appetite and insomnia, tachycardia and hypertension may be evident also

Generalised seizures can also occur usually within the first 24 hours of alcohol withdrawal

Question 18

How long does it usually take for the symptoms of alcohol withdrawal to resolve? When are the symptoms at their worst?

Answer 18

usually start in the first few hours and resolve after 5-7 days.

Symptoms are at their worst at 48 hours.

Question 19

How do you manage alcohol withdrawal?

Answer 19

Give the patient general support and advice

If necessary then treat the withdrawal by giving the patient benzodiazepines - preferably long acting benzos are given eg Diazepam or chlordiazepoxide

Question 20

Which benzo cannot be given if there is evidence of liver damage? How long must the benzos be given for? What must be given as vitamin supplementation?

Answer 20

If there is evidence of liver damage, then do not give the patient chlordiazepoxide

Reduce the benzo dose gradually over 7 days

Give vitamin B1 - thiamine supplementation as prophylais against Wernicke’s encephalopathy

Question 21

How is the thiamine supplementation given to prevent Wernicke’s encephalopathy? What is done if wernicke’s encaphlopathy is suspected?

Answer 21

It is given IV route to prevent the possible Wernicke’s

If Wernicke’s encephalopathy is suspected, then give the patient high dose thiamine

Question 22

What is the syndrome that can occur which represents the most severe withdrawal from alcohol?

Answer 22

This is delirium tremens

Question 23

How does delirium tremens present? When does it present also?

Answer 23

It often presents insidiously with nighttime confusion.

You get confusion, agitation, fever, visual and auditory hallucinations and paranoid ideation

Peak onset is 2 days after abstinence

Question 24

How would you treat a patient with delirium tremens who was agitated and needed sedating?

Answer 24

Lorazepam - fast acting benzo

Question 25

Majority of patients can be detoxified in the community. Inpatient treatment if * A history of Delirium Tremens or alcohol withdrawal seizures Severe dependence * A history of failed community detoxifications * Poor social support Cognitive impairment * Psychiatric co-morbidity Poor physical health * Delirium Tremens requires prompt transfer to general medical ward.

What psychosocial interventions can stop relapse?

Answer 25

* CBT for the patient

* Motivational enhancement therapy

* 12 step facilitation eg alcoholics anonymous

Also can try * Family and couple therapy * Behavioural self controlling therapy

Question 26

Does benzodiazepines have a place for helping prevent relapses in alcohol dependency?

Answer 26

There is no place for benzodiazepines beyond the detoxification period

Question 27

What pharmacological therapy can help stop relapse in alcohol addiction?

Answer 27

Disulifram (also known as antabuse)

Acamprosate

Naltrexone

Question 28

What is the mode of action of disulifram? Why is disulfiram used?

Answer 28

Disulifram (antabuse) - inhibits the acetaldehyde dehydrogenase leading to the accumulation of acetaldehyde if alcohol is ingested there is a build up of acetaldehyde

When alcohol is suggested there is a build up of acetalhyde which causes different side effects

Question 29

What does the build up of acetaldehyde if alcohol is ingested cause? What does the efficacy of disulfiram therefore depend upon?

Answer 29

Cause flushed skin, tachycardia, nausea+vomiting, arrhythmia and hypotentison depending on volume of alcohol consumed

The efficacy of this drugs therefore depends on the patients compliance

Question 30

What were the other two drugs that can be given for relapse prevention?

Answer 30

Acamprosate and naltrexone

Question 31

How does acamprosate work? When should it be started?

Answer 31

Acamprosate acts centrally on glutamate and GABA systems (believed to be an NMDA receptor antagonist - reduces glutamate) (increases effects of inhibitory neurotransmitter GABA)

Start this drug as soon as detoxification finishes if choosing this method

Question 32

What are side effects of acamprosate? What is the first line drug for relapse prevention?

Answer 32

Acamprosate can cause headaches, diarrhoea, nausea and vomiting

Naltrexone is generally first line for preventing relapse - it is an opioid antagonist and reduced reward from alcohol as well as the cravings

Question 33

State what the three options were again and how they work? What was first second and third line?

Answer 33

1. Naltrexone - generally first line for relapse prevention - works on the opioid receptors specifically the MOP channel - reduces reward from alcohol and reduces cravings
2. Acamprosate - NMDA-glutamate antagonist and GABA agaonist
3. Disulifram - acetylaldehydre dehydrogenase inhibitor so leads to accumulation of acetyladehyde which reacts when alcohol is ingested - flushed skin, tachycardia

Question 34

What is wernickes encephalopathy? What is the classic triad? What is the treatment for Wernicke’s encephalopathy?

Answer 34

Wenicke’s ecnaphalopthy is due to a vitamin B1 deficiency (thiamine) - chronic alcohol abuse interferes with the uptake of thiamine in the gut leading to this deficiency

The encephalopathy classically presents with the triad pf confusion, ataxia (wide based gait) and ophthalmoplegia - nystagmus, lateral rectus or conjugate gaze palsy

Treatment is to give high dose thiamine .

Question 35

What is Korsakoff’s encephalopathy?

Answer 35

This is the progressed state from wernicke’s encephalopathy

Question 36

What percentage of patients with Wernick’es encaphalopathy go on to develop Korsakoffs syndrome? What is korsakoffs characeterized by?

Answer 36

85% of patients go on to develop Korsakoff’s

In Korsakoffs, there is hypothalamic damage and cerebral atrophy due to thiamine deficiency

Patient presents with anterograde (inability to form new memories) and retrograde amnesia (forget all the old memories), there is also confabulation and a lack of insight and apathy

Question 37

What is confabulation?

Answer 37

This is where the patient invents memories upon questioning to make up for the gaps in their memory due to the amnesia

Question 38

What is the treatment of Korsakoff’s syndrome?

Answer 38

IV thiamine followed by oral thiamine - very poor prognosis