ALCOHOL MISUSE

By THARINDU HETTIARACHCHISouth Asian Institute Technology & Medicine

Malabe.

Introduction

Alcohol misuse is drinking excessively more than the recommended limits of alcohol consumption.

recommended safe limits of alcohol:Men maximum up to 21 units of alcohol per week.Women maximum up to 14 units of alcohol per week. One alcohol unit is measured as 10ml or 8g of pure alcohol. This can lead to a number of harmful physical, social and psychological effects, such

as alcohol poisoning, cirrhosis of the liver, inability to work and socialize and destructive behaviors.

Risk of developing problems increases with the amount of alcohol intake at a time.

Types of alcohol A)Distilled liquors Brandy, Whisky, Arrack, Vodka, Rum(30-50%)

B)Fermented liquors Beer, Toddy, Fortified wines (04-18%)

C)Compound liquors Gin (40-50%)

Why People Consume Alcohol?

I. Due to Tolerance & Dependence.

II. Peer Pressure.

III. Genetic predisposition.

IV. Social and Religious customs.

V. To show their social status.

VI. To temporary relieve stress.

VII.As a result of personality characteristics.(aggressiveness, anxiousness, depression)

VIII.Influence from the alcoholic beverage industry.

IX. Easy accessibility.

X. To relive physical pain.

XI. To experiment/ or as a social drinker.

Epidemiology

Alcohol per capita consumption(in liters of pure alcohol)

Source: WHO/2014

Type of alcohol

Average Alcohol per capita consumption from 2003 to 2010

Prevalence of Heavy drinking in 2010

Source: WHO/2014

Prevalence of Alcohol dependence & Alcohol associated disorders

Alcohol usage by Age in 2015

Source: WHO/2014

Age of Alcohol initiation

Blood Alcohol Concentration & Effects

< 0.05 : sobriety, talkative, sense of well being. 0.05-0.1 : euphoria, slurring of speech, loss of concentration and sensory perception, bravado. 0.1-0.2 : excitement, emotional instability. 0.2-0.3 : disorientation, confusion, dizziness, impaired balance. 0.3-0.4 :stupor, lack of response, fecal and urinary incontinence. 0.4-0.5 :coma, depressed reflexes. > 0.5 : fatal, respiratory failure.

Factors Depend on BAC

Gender: higher in Female. Age: higher in younger people. Weight: smaller the body higher the BAC. Rate of consumption: faster a person consumes drinks, quicker BAC will rise. Strength of drink: maximum absorption is for 20% alcohol drinks. Food in stomach: reduce absorption. Nature of meal: fatty meals slow gastric emptying so, delays the absorption. Liver function. Genetic Factors.

History taking & Examination

Consider possible alcohol problems in high risk groups:

Medical/psychiatric conditions associated with excessive use.

Marital or sexual problems.

Trouble with the law.

Repeated absent or poor record at work.

Problems with their family & children. Ask screening questions or use a screening questionnaire(AUDIT, CAGE) Ask for any symptoms of alcohol dependence. Previous treatments for alcohol dependence. Circumstances surrounding relapse: internal cues and external triggers. Family history of alcohol dependence and other mental illnesses.

Physical examination for alcohol related medical conditions(GI symptoms, withdrawal fits, Delirium Tremens)

Alcohol further investigations.

Laboratory investigations(MCV, blood alcohol con, GGT, urate level)

Alcohol diary(Current level of intake: volume, type,% of alcohol, days per week)

Alcohol Screening Questionnaires

AUDIT- Alcohol Use Disorders Identification Test

CAGE questionnaire

AUDIT questionnaires

CAGE questionnaire

C – Have you ever felt that you should cut down your drinking? A – Do people annoy you by criticizing your drinking? G – Have you ever felt guilty about your drinking? E – Have you ever had a drink as the first thing in the morning?If two or more of the above are positive-drinking excessively- risk drinker.One mark is an indication for further enquiry about person’s drinking.Its less sensitive but, more specific as score is 3 or more.

Effects of Alcohol

Physical Effects

Neuropsychiatric Effects Social effects

Physical Effects GIT

Gastritis, vomiting, hematemesis Diarrhea Pancreatitis Alcoholic liver disease

CVS Cardiomyopathy, arrhythmias Hypertension, cholesterol Cerebrovascular accidents, MI

RS Exacerbation of asthma Aspiration pneumonia

Genitourinary Subfertility, sexual dysfunction. acute retention

Dermatological Psoriasis, discoid eczema, rosacea Low-grade bacterial/fungal skin infections (50%)

Neurological Encephalopathy (W-K) Blackouts, faints, fits, coma Neuropathy, myopathy

Nutritional Wernicke-Korsakoff syndrome Malnutrition, obesity anemia Pellagra

Metabolic Hypoglycemia DM – poor control Gout Other metabolic Disorders

Miscellaneous Trauma Abnormal Response to medicines (non-compliance / drug interactions) risk of breast cancer

Neuropsychiatric EffectsAlcohol related psychiatric disabilities fall into four groups

I. Abnormal Forms of Intoxication.

II. Withdrawal Phenomena.

III.Chronic or Nutritional disorders.

IV. Associated psychiatric disorders.

Abnormal forms of intoxication

People who consume dangerous amounts of alcohol persistently develop two syndromes.

I Memory blackoutsLooses of memory for events that occurred during a period of intoxication.

When they occur regularly they indicate frequent heavy drinking; when they are prolonged, it affects greater part of a day or whole day.

II Idiosyncratic intoxication/Pathological drunkennessMarked change in behavior occurring within minutes of taking alcohol in amounts that would not induce drunkenness in most people.

Often behavior can be aggressive

It’s a rare condition.

Withdrawal Phenomena

Alcohol withdrawal syndrome

Alcohol dependence syndrome

Alcohol dependence syndrome A cluster of behavioral, cognitive, and physiological phenomena that develop after

repeated substance use and that typically include a strong desire to take the alcohol, difficulties in controlling its use, persisting in its use despite harmful consequences.

They get withdrawal effects after a few hours and have to take alcohol to avoid the withdrawal symptoms, thus they drink every few hours of the day (relief drinking)

They start with morning drinking which is another feature of the syndrome Typically they hide bottles in various places so that they can ‘top up’ and not allow others

to notice their frequent drinking. They start drinking the cheapest and strongest drinks to get their requirement at a lesser

cost.

They develop further physical, social and psychological damage due to this drinking and develops stereotyped pattern of drinking. (drinks at regular intervals to relieve or avoid withdrawal symptoms)

If they manage to decreases drinking they improve physically sometimes quite, and able eating and sleeping well.

If they take even one drink after abstinence they are vulnerable and may get back to earlier pattern of uncontrolled drinking very soon.

ICD- 10 Criteria For Diagnosis of ADSA definite diagnosis of dependence should usually be made only if three or more of

the following have been present together at some time during the previous year.

A strong desire or sense of compulsion to consume alcohol. Difficulties in controlling substance-taking behavior in terms of its onset,

termination, or levels of use. Evidence of tolerance, such that increased doses of the psychoactive substances

are required in order to achieve effects originally produced by lower doses. Progressive neglect of alternative pleasures or interests because of psychoactive

substance use, increased amount of time necessary to obtain or take the substance

or to recover from its effects.

Persisting with substance use despite clear evidence of overtly harmful consequences,

such as harm to the liver through excessive drinking.

A physiological withdrawal state when substance use has ceased or been reduced, as

evidenced by: the characteristic withdrawal syndrome for the substance or use of the

same (or a closely related) substance with the intention of relieving or avoiding

withdrawal symptoms.

Course and Prognosis of ADS

Syndrome become established in mid forties for men, and few years later for women. Now occurring increasingly among teenagers. Once established, the syndrome usually progresses steadily and destructively. Severely dependent person who achieves abstinence but then drink again, is likely to

relapse quickly and totally, returning to his old drinking pattern within few days. (reinstatement after abstinence)

Alcohol withdrawal syndrome It’s set of symptoms that can occur when an individual reduces or stops alcoholic

consumption after long periods of use. Prolonged and excessive use of alcohol leads to tolerance and physical dependence.

The withdrawal syndrome is largely a neuropsychiatric excitability and autonomic disturbances due to lack of alcohol.

About half of people with alcoholism will develop withdrawal symptoms upon reducing their use. Of these, about three to five percent develop DTs or have seizures.

Signs and symptoms of AWS Signs and symptoms of alcohol withdrawal occur primarily in the central nervous

system. The severity of withdrawal can vary from mild symptoms such as sleep disturbances and anxiety to severe and life-threatening symptoms such as delirium, hallucinations, and autonomic instability.

Earliest and commonest feature is acute tremors affecting hands, legs and trunk. Severity of symptoms is dictated by a number of factors, the most important of which is

degree of alcohol intake, length of time the individual has been using alcohol, and previous history of alcohol withdrawal.

Nausea and sweating are frequent and if alcohol is taken these symptoms relieved quickly.

As withdrawal progresses, misperceptions and hallucinations may occur. Later epileptic seizures and finally delirium tremens after 48 hours.

Delirium tremens Severe form of withdrawal syndrome that occurs when the patient is physically dependent on alcohol. Usually occurs after 2 days and can last for 3-4 days. Symptoms are characteristically worse at night. Ends in deep and prolonged sleep from which the person awakes with no symptoms and little or no

memory of the period of delirium. Features are,

I. Delirium Features( clouding of consciousness, disorientation of time and place, impaired recent memory)

II. Specific features(gross tremors in hand, autonomic disturbance, insomnia)

III. Hallucinations(mainly visual)

IV. Dehydration and electrolyte disturbance.

Treatment: Withdrawal treatment & general measurement for treating delirium.

Severity of alcohol problems and the type of intervention

ALCOHOLPROBLEMS

NoneMild

ModerateSubstantial

Severe

Specialized treatment

Brief intervention

Primary prevention-------------------------------------------------

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Management of Alcohol Withdrawal

Pharmacological Intervention Non-Pharmacological InterventionDetoxification CBTBenzodiazepines Group therapyAversion agents DisulfiramCarving reduction agentsNaltrexoneAcamprosate

Detoxification Sudden cessation of drinking may cause severe withdrawal symptoms so, detoxification should

carried out under medical supervision. Could be planned or unplanned. More severe cases frequent supervision and psychological support to maintain motivation. Long acting Benzodiazepine: Chlordiazepoxide/Diazepam In moderate dependence: 10-30mg of Chlordiazepoxide 4times daily, gradually reduced over 5-

7 days. In severe dependence: 10-50mg of Chlordiazepoxide 4 times daily, gradually reduced over 7-10

days. (Maximum daily dose 250mg)

Benzodiazepines should not continued for longer than 14 days due to dependency.

Course of high dose Vitamin B orally or parental 50-100mg daily. If history of seizure present use phenytoin. Monitor symptoms, blood pressure and fluid intake.

Anti-craving agents Reduces positive reinforcing effects of alcohol. In combination with counselling, may be helpful for maintaining abstinence in alcohol

dependent patients. It should be initiated as soon as possible after abstinence has been achieved and

continued for 1 year. Acamprosate: Stimulates GABA receptors and decreases the effects of Glutamate.

Dose:666mg 3times daily. Naltrexone: opioid antagonist which used as tablets or implants.

Dose 50mg daily.

Post relapse prevention Disulfiram used as an adjunct in treatment of alcohol dependence. It gives extremely unpleasant systemic reaction(flushing reaction:

Tachycardia, dyspnea, headache, vomiting, hypotension) after ingestion of even a small amount of alcohol as it inhibits Aldehyde Dehydrogenase which causes accumulation of acetaldehyde in the body.

Only effective if its taken daily & reaction can last for several hours. Dose should be 200-400mg daily. (maximum up to 500mg) During treatment patient should be monitored 2weekly for first 2 months and

each month for the following 4months and at least every 6 months thereafter.

Non-Pharmacological Interventions

Brief Interventions: Assessment of alcohol intake, inform on harmful effects drinking and clear advice for

the individual.

Relapse prevention: Identifying, addressing and minimizing risk factors. Social skills training, relaxation techniques. Self-helps groups useful in helping to maintain motivation. (AA) The transtheoretical model of behavior change assesses an individual's readiness to act

on a new healthier behavior, and provides strategies, or processes of change to guide the individual through the stages of change to Action and Maintenance.

It proposed that deciding to stop using a substance is a behavioral change which occurs in a series of steps.

Toxic & Nutritional Conditions

There are two neuropsychiatric disorders in this group

A. Wernicke-Korsakov syndrome.

B. Alcoholic Dementia.

Wernicke-Korsakov’s SyndromeIs the combined presence of Wernicke's encephalopathy (WE) and Korsakov’s psychosis.

Main cause of this syndrome is the thiamin(vitamin B1) deficiency.

Alcohol abuse is the most frequent cause, act by causing deficiency in thiamin.

Clinical Features: Impairment of consciousness. Impairment of recent memory. Disorientation in time. Ataxia & opthalmoplegia.

Treatment:

Case is due to thiamine deficiency vitamin B should prescribed with treatments to alcohol abuse.

Alcoholic Dementia

Alcoholic dementia can occur after a prolonged heavy intake of alcohol.

Intellectual impairment often associated with enlarged ventricles and widened cerebral sulci can be seen in CT scan.

Cause is uncertain but probably due to direct toxic effect of alcohol on the brain and secondary effects of liver disease.

Prognosis: After prolonged abstinence some gradual improvement occurs.

Associated Psychiatric disorders Depressive Disorders

It can be induced by prolonged dangerous use of alcohol.

Anxiety Disorders

Occur commonly during periods of partial withdrawal. Also this can lead to deliberate self-harm & suicidal behaviors.

Most common in people who use alcohol heavily than other people in the same age.

Personality changes

Heavy users of alcohol often includes lack of concern for others, decline in standards of conduct, honesty and responsibility.

Pathological Jealousy

It’s infrequent. Most common is non-delusional suspiciousness of the sexual partner.

Sexual dysfunction

It’s a common condition, usually as erectile dysfunction or delayed ejaculation.

Cause includes due to direct effect of alcohol, and generally impaired relationship with sexual partner.

Transient Hallucination

Auditory and visual hallucination are reported by heavy drinkers, generally during withdrawal.

Alcoholic Hallucinosis

Rare condition characterized by distressing auditory hallucinations usually voice uttering threats, occur in clear consciousness.

Social Effects

Excessive Drinking can cause serious social damage including, Family violence Poor work performances and sickness absence. Unemployment. Economical problems. Emotional and conduct problems in the patient’s children. Road traffic accidents. Crimes( Fraud, Sexual offences, Murder)

Preventing Alcohol-related Harm

Population based approaches Individual approaches

I. Population based approachesAim is to is to reduce the average level of consumption in population so, reduce the amount of alcohol problems.

II. Raising the price of alcoholic drinks by taxation.

III. Licensing laws to limit the hours when alcohol is available.

IV. Control of advertising and media of alcoholic drinks.

V. Controlling the sale of alcohol by limiting sales in shops.

VI. Health education programmes

Individual based approachesFocus on identifying individuals who are consuming hazardous or dangerous amounts of alcohol and intervening with aim of avoiding or limiting alcohol-related harm.

Reference

i. Oxford Core Texts of Psychiatryii. Alcohol & drug information center Sri Lanka(http://www.adicsrilanka.org)iii. Sri Lankan college of Psychiatrists (http://slcpsych.lk/site/)iv. Sri Lanka Journal of Psychiatry(sljpsyc.sljol.info/)v. Sri Lanka-WHO(www.who.int/substance abuse/publications/global alcohol.../lka.pdf)vi. Research & Publications- University of Colombo.

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