Alcohol use disorders and withdrawal +NPC

How many grams of alcohol does 1 standard drink contain?

1 STD drink =10g alcohol

D/Dx in heavy drinker

1) Intoxication with Alcohol. 2) Withdrawal from Alcohol. 3) Intoxication with a drug other than Alcohol. 4) Withdrawal from a drug other than Alcohol. 5) Hepatic Encephalopathy. 6) Systemic infection- ie. Septicaemia/Meningitis. 7) Hypoglycaemia. 8) Wernicke's Encepalopathy. 9) Post ictal state. 10) Head injury (Sub-dural haematoma.)

What things will you do to achieve said goals?

1. Initiate an alcohol withdrawal chart 2. Give him IV fluids 3. Drug therapy

Which 7 signs/symptoms are monitored on the Alcohol withdrawal scale (AWS)?

1. Persperation/sweating 2. Tremor 3. Anxiety 4. Agitation 5. Axilla temperature 6. Hallucinations 7. Orientation

ADH activity is significantly reduced in which 3 circumstances?

1. alcohol dependence 2. H Pylori infection 3. Elderly men

How can you "screen" for alcohol use disorders?

A variety of screening tools are available. The National Institute of Alcohol Abuse and Alcoholism (NIAAA) recommends the use the CAGE questionnaire. AUDIT-Abbreviated alcohol use disorders identification test

What effects does alcohol have on the GIT system?

Acute oseophagitis Anorexia and abdo pain Direct toxic affect on the gastric mucosa Beer and wine stimulate acid secretion* GORD

Why does the rate of alcohol metabolism stay the same regardless of having 2 drinks or 12?

Alcohol has a very high affinity for ADH, and it gets saturated even at low concentrations. Results in a relatively constant rate of metabolism ie. ZERO ORDER KINETICS over a wide range of concs. Average rate is 7.5g per hour. Ie. almost 1 STD drink per hour

What is alcohol withdrawal?

Alcohol intake depresses the CNS, therefore withdrawal produces over-excitation of the nervous system. Neuroadaptation to the effects of chronic alcohol use results in: -Decreased activity of GABA-A receptors -Up-regulation of NMDA as well as voltage gated ca2+ channels Compensatory hyperactivity leads to profound hyper-excitability of the CNS once alcohol is withdrawn ie. seziures.

What physiological effect does alcohol have on our CNS receptors?

Alcohol is a CNS depressant- enhances the effects of GABA at the GABA-A receptor 1. Opens chloride channels- working as an anxiolytic, muscle relaxant and sedative effects 2. Inhibits Glutamate by blocking ca2+ linked NMDA receptors- stopping influx of calcium which normally activate neurons- causes the amnesic and cerebral depressant effects

What is the mechanism by which alcohol can induce hypertension?

Alcohol is a vasodilator-causes a mild drop in BP and a compensatory increase in sympathetic system (inc. HR and CO), causing decreased myocardial contractility and peripheral vasodilation. As a result BP may rise!

What is fetal alcohol syndrome? Describe the neurological affects as well as characteristic facial features.

Alcohol use during pregnancy causes: IUGR Poor post natal growth Microcephaly Developmental delays Attentional deficits-Hyperactivity Learning disabilities Microphthalmia with short papebral fissues Midface hypoplasia Thin upper lip Smooth/long philtrum

How does chronic alcohol use affect its metabolism?

CYP usually plays a minor role in metabolism but becomes important at high BACs. The amount and activity of Cyp is induced by chronic alcohol consumption- plays a role in dependence. The induction can increase the metabolism of other drugs metabolised by 2E1. Both pathways use NAD+ resulting in a decrease in the ratio of NAD+/NADH which contributes to acidosis in alcoholics.

What is motivational interviewing?

Motivational interviewing -get the patient to list the benfits and costs -show assoc. of drug use with any medical problems (HTN and alcohol) summarise statements rephrase statements ie. "so you dont think there are any negative aspects to your amphetamine use?"

What non-drug treatments are useful in a pt such as this?

Move him to a quiet room and dim the lighting

Alcohol use disorder DSM-5 Criteria?

Note: alcohol abuse and alcohol dependence are now a single disorder called alcohol use disorder (AUD). The presence of at least 2 of these symptoms indicates an Alcohol Use Disorder (AUD) which can then be rated as mild, mod, severe.

In a nontolerant person, a blood alcohol level over what can cause death?

Over 400 mg/dL can produce respiratory failure, coma, and death.

Which benzo is preferable to Diaz in the elderly or pts with liver disease?

Oxazepam

Which things affect the ABSORPTION of alcohol? Is this pharmacokinetics or dynamics?

Pharmacokinetics (ADME) Absorption can be rapid because its small and highly water soluble. Rate of absorption depends on: 1. speed of transit through the stomach 2. Nature of the alcohol. Concentration (30% or less) abs is rapid. However (40% or more ie. spirits) cause irritation of gastric mucosa and pyloric spasm and delay stomach emptying!

How does stomach emptying (eating before you drink) affect alcohol absorption?

Rate of absorption in the stomach is slow but rapid in the Small intestine. If gastric emptying is delayed by food-->absorption (ie. arrival in the SI) is delayed and the peak BAC will be lower and later than when the same dose is taken on an empty stomach.

What is cage?

Specify "during the past 12 months". Have you ever felt you ought to *Cut down* on your drinking? Have people *Annoyed* you by criticizing your drinking? Have you ever felt bad or *Guilty* about your drinking? Have you ever had a drink first thing *Eye-opener*? in the morning to steady your nerves or get rid of a hangover Two "yes" answers correctly identify 75% of problem drinkers. Three "yes" answers raises this specificity to over 95%.

On admission his: (GGT) is 240 units/L (normal range 0-60) (MCV) 107 fL (normal range 80-100) Serum creatinine level is 180 micromol/L, electrolytes are normal Would we be interested in treating the macrocytosis?

This is inappropriate as a short term goal. It is very likely to be due to his chronic alcohol intake. You should not attempt to treat until you know his B12 and folate status. In any case, such treatment, if indicated, is not urgent.

How will you monitor this mans progress?

UEC LFTs Temperature, Oxygen sats Level of consciousness

In a non tolerant person, at what alcohol level might you start to see behavioral changes, slowing of motor performance, and decrease in the ability to think clearly?

blood alcohol level as low as 20 to 30 mg/dL

What blood tests do you do for alcohol use disorder?

• For recent consumption - Blood alcohol • For "chronic" consumption- GGT, *AST*, ALT, MCV, *CDT*

What medications are used in relapse prevention/anti craving meds?

• Naltrexone (1994) • Disulfiram (1950) • Acamprosate (...)

What clues might there be to a possivlve alcohol problem based on past medical HX?

• Recurrent trauma • Pancreatitis, GE reflux, dyspepsia, gastritis • Fatty liver, alcoholic hepatitis, cirrhosis • Hypertension, cardiomyopathy, arrhythmias • Dementia, cerebellar disease, peripheral neuropathy, Wernicke-Korsakoff syndrome • Dupuytren's contractures

In the hospital BAL is usually written as mmol/L. What would a BAL of .05, .1 and .15 equate to in mmol/L?

• To convert mg/100ml to mmol/l: i) divide the milligrams by the molecular weight of alcohol, 46.07 ii) multiply by 10 because 100ml to 1000ml is a ratio 1:10. Example: 50mg/100ml of blood (0.05) BAL to SI units 50/46.07 x 10 = 10.85 mmol/l 10mmol/L 20mmol/L 30mmol/L

Complications associated with the Withdrawal Syndrome

•The syndrome of delirium tremens the may lead to volume depletion and vascular collapse. •Infection, particularly of the lung. •Withdrawal fits may lead to status epilepticus (rare). •hyperthermia. •Hypokalaemia •Hypomagnesaemia leading to rhythm disturbances. •Hyponatraemia or hypernatraemia •Myocardial infarction. •Cardiac failure.

Which 3 things do you need to gauge on an alcohol HX?

1. level , frequency, pattern of alc consumption 2. symptoms of dependence 3. physical, psychological, social problems related to drinking

What are the 7 main elements of treatment for alcohol use disorder?

1.Set abstinent drinking goal. 2.Treat alcohol withdrawal. 3.Treat medical complications 4.Refer patient to inpatient or outpatient treatment program and mutual-aid group, e.g., AA 5.Discuss family treatment (e.g.,AlAnon). 6.Consider pharmacotherapy (e.g., naltrexone). 7. Treat concurrent mental illness. 8. Provide ongoing support to patients and their families.

DSM-V Criteria for Substance Use Disorder (11 criteria) Criteria 1-3

2 in 12mo of recurrent/continued use despite: 1. Role obligation failed 2. Physical hazard 3. Interpersonal problems A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 2 (or more) of the following, occurring within a 12 month period: 1. Recurrent substance use resulting in a failure to fulfil major role obligations at work, school, or home 2. Recurrent substance use in situations in which it is physically hazardous (e.g. driving an automobile when impaired by substance use) 3. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance

Which two mental health co-morbidities are alcoholics likely to have?

25% alcohol dependents have anxiety 20-40% have depression

Define Binge drinking

3 or more occasions in a fortnight, in which 6 or more consumed in males and 4 in females.

Which receptor does alcohol affect that is responsible for the pleasure and nausea associated with alcohol intake?

5-HT3 receptors

What are the *four* NRMHC guidelines on drinking alcohol?

Apply equally to men and women: 1. Drinking no more than 2 STD drinks on any day reduces lifetime risk of harm from alc-related disease and injury 2. No more than 4 std drinks on a single occasion- prevents injury on that occasion 3a. children and people under 15yrs are at the greatest risk of harm form drinking- especially important for this age group b. For young people 15-17 yrs safest option is to delay initiation of drinking for as long as possible 4. For pregnant women, not drinking is the safest option b. Not drinking while breastfeeding is the safest option

Criteria 6-11

BRIEF: 6. Larger amounts 7. Cut down attempts - failed 8. Time wasted 9. Importent activities given up 10. Physical/mental health issue exacerbated 11. Craving 6. The substance is often taken in larger amounts or over a longer period than was intended 7. There is a persistent desire or unsuccessful efforts to cut down or control substance use 8. A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects 9. Important social, occupational, or recreational activities are given up or reduced because of substance use 10. The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance. 11. Craving or a strong desire or urge to use a specific substance.

Why do women get drunk faster than men?

Because alcohol distributes rapidly throughout body water-crossing the BBB and placenta. Females have a smaller amount of body water proportional to males- women get drunker quicker.

How is blood alcohol level measured?

Blood alcohol level is expressed as grams of alcohol per 100ml blood (%). 50mg alcohol per 100ml blood is BAC 0.05% BAC: (0.02 X No. of std drinks) - (0.015 x no. of hours)

What is a 'brief intervention'?

Brief interventions are short counselling sessions that can be as short as 5 minutes. A structured therapy for 30 mins, using FLAGS 1. Feedback on risk/impairments due to drug use 2. Listen to the patients concerns 3. Advise patients about the consequences of continued drug use 4. Goals of treatment should be defined for example to reduce or cease drug consumption 5. Strategies for treatment should be discussed and implemented-identify triggers to drug use and strategies to overcome them-offer follow up appointment

Mr Grant is 77 years old and lives alone (admitted 24 hours ago with pneumonia which is being treated well with antibiotics) You are rung at midnight by the ward nurse. She says that the patient is not sleeping, is confused, restless and very noisy. On examination he is disorientated, inattentive, tremulous and appears to be having visual hallucinations. HR 106 Sweating with a temperature of 38.4 °C. Admission notes refer to a past history of heavy drinking and smoking. What are your short term therapeutic GOALS for Mr Grant?

Control his acute confusional state Prevent DTs Prevent permanent neurological damage Prevent him injuring himself or others

What effect can alcohol have on blood cells?

Days to weeks of heavy drinking can cause reversible -increase in RBC size (MCV) -mild macrocytic anaemia -leucocytopenia -thrombocytopenia, decreased PLT aggregation and inhibit release thromboxane A2

What is Delirium Tremens (DTs)? Is this just normal withdrawal?

Delirium Tremens is a major withdrawal syndrome- serious medical emergency. 3-10 days after the last drink, pts can suffer: Agitation Disorientation High fevers and sweating Paranoia and visual hallucinations Occurs in 5% or fewer, rarely in pts under 30. Can last a few hrs to 2 weeks

What is Disulfram? Which part of the metabolising process does it inhibit?

Disulfram is an aversive agent used in alcoholics to deter drinking. It inhibits aldehyde dehydrogenase (ALDH) so if the person is to have even a small amount it causes a build up of toxic acetylaldehyde. Sx include: Flushing, tachycardia, hyperventilation and headache-can get quite ill!

Who are brief interventions useful for?

Extremely effective in heavy users who are not yet dependent. Once dependent brief interventions don't have much effect..

T/F- knowing the blood alcohol level in someone in withdrawal is useful

False! By definition, his blood alcohol level will be low because he is in a withdrawal state. Since you have no idea of how high it has been, the level will be of no help to you.

What are some signs/symptoms of chronic alcohol intake?

General appearance -evidence of agitation (due to a withdrawal state), premature ageing, malnutrition, cushingoid facies Vitals -inc. pulse rate and BP Signs of intoxication -alcohol on breath, garrulousness, ataxia Signs of withdrawal -tremor and sweating of hands, tremor of face and tongue Cutaneous stigmata -facial telangiectasia, dupytrens, bruises -Evidence of cardiac enlargement -Liver disease - hepatosplenomegaly Neurology -Head injury? -Nystagmus or opthalmoplegia -Ataxia, especially stance and gait -Signs of peripheral neuropathy

Discuss the metabolism of alcohol. Which organ does it occur in? Name the 2 metabolites of Ethanol and the 2 enzymes necessary.

In the LIVER! Two enzymes catalyse the first step: 1. cytosolic alcohol dehydrogenase (ADH)* Major route 2. Microsomal enzyme Cytochrome p4502E1

iMPORTANT ERRORS

Late use of sedative medication Under use of sedative medication Failure to diagnose other conditions

When does withdrawal start?

Many chronic users will develop tremors within 24 hrs after last drink. Peaks on day 2-3 of abstinence major symptoms subside by day 4-5.

How is the severity of the AUD classified?

Mild: The presence of 2 to 3 symptoms Moderate: The presence of 4 to 5 symptoms Severe: The presence of 6 or more symptoms

What are some signs of intoxication?

Mood elevation muscle relaxant Impaired balance, speech, vision and coordination Unconscious, deep coma, death

Which type of seizures can withdrawal precipitate? Are they common?

Most commonly in the first 48 hrs Generalized seizure-Grand mal type, self limited, 1-4 seizures Occurs in 15% of withdrawing alcohol users.

How do we treat alcohol withdrawal?

You cannot STOP withdrawal. You can just treat the symptoms. 1. Diazepam IV 10mg, over 1-2mins-ONCE ONLY, Initial therapy if pt cannot take orally 2. Diazepam 10-20mg, PO 1-2hrly PRN to decrease hyper excitability and prevent seizures- titrate benzos according to AWS-do not discharge on benzos. 3. Thiamine 100mg IV/ IM daily for 5 days- always give thiamine to prevent Wernickes encephalopathy Always refer to an alcohol treatment service

How does DSM-5 define tolerance?

a. Increased amounts needed b. Diminished effect w. same amount a. a need for markedly increased amounts of the substance to achieve intoxication or desired effect b. markedly diminished effect with continued use of the same amount of the substance

How does DSM-5 define withdrawal?

a. the characteristic withdrawal syndrome for the substance b. the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms