ALCOHOL ABUSE

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					                                     ALCOHOL ABUSE:


Alcoholism is a disorder marked by a pathological pattern of alcohol use that causes serious
impairment of social or occupational functioning.

Alcohol related disease is a significant problem in general hospitals. About 25% of patients in
general hospitals have alcohol related pathology.

Griffith Edwards and Gross(1976) defined some simple markers of alcoholism. These are:

       dependent drinkers have a narrow repertoire of alcohol consumption: alcohol is used
        to avoid withdrawal symptoms
       drinking overtakes the individual's activities to the exclusion of everything else,
        leading to theft, begging and borrowing
       withdrawal symptoms include trembling, fear, insomnia, nightmares, sweating and
        hallucinations.
       tolerance develops so that the dependent drinker consumes quantities which might
        make non-drinkers unconscious
       dependent drinkers know that they cannot control their alcohol use
       there is a high tendency to relapse after abstinence

Alcohol withdrawal symptoms occur within 12 hours of the last drink.


Epidemiology:

In the UK there are approximately:

       5 million non-drinkers
       40 million social drinkers
       10 million "at risk" drinkers
       1 million problem drinkers
       200 000 dependent drinkers

Hospital admissions for alcoholism average 20,000 per year. Each year 5,000 to 10,000
people die prematurely from alcohol abuse. The more alcohol a population consumes the more
alcohol-related damage will result, and consumption has been increasing steadily in England
since the second world war.

Deaths from liver cirrhosis relate closely to heavy drinking and rates are rising in most
countries. Men under 25 years of age have the highest rates of problems related to alcohol
and 25% of males in a South London survey had suffered some social or economic disruption
through drinking. Criminal offences related to drunkeness have increased alarmingly.

Some occupations give rise to an increased risk of alcoholism, for example doctors, sailors and
demolition workers.

There are four levels of alcohol use:

       social drinking:
            o only 10% of the UK population do not drink alcohol
            o healthy drinking in defined as less than 21 units/week for men and less than
                 14 units/week for women
      at risk consumption:
            o the level of drinking begins to pose a health risk

      problem drinking:
           o drinking causes serious problems to the patient, the family, work and society
              in general
           o 1-2% of the population have a drink problem

      dependence and addiction:
          o periodic or chronic intoxication
          o uncontrollable craving for drink when sober
          o tolerance to the effects of alcohol
          o psychological and/or physical dependence
          o there are 200,000 dependent drinkers in the UK

Risk Factors for alcoholism:

Alcohol consumption may be correlated with several variables:

      sex:
           o   men are twice as likely to be problem drinkers

      occupation:
           o publicans and brewers have an increased access to drink and are at a higher
              risk
           o heavy drinking is seen as the norm in some jobs e.g. doctors & sailors

      homelessness:
          o a third of homeless people have a drink problem

      race:
           o   British Afro-Caribbeans and Asians have a lower rate of drink problems
           o   20% of Chinese and Japanese cannot drink alcohol because of an inherited
               deficiency of acetaldehyde dehydrogenase

Clinical Features:

Characteristic behaviours include a tendency to gulp drinks, to have extra drinks before going
to social events, drink on their own, lie about how much alcohol they consume, drink on the
way home, and to keep alcohol with them.

Features related to physical complications of alcohol abuse:

      Korsakoff's syndrome - retrograde amnesia and confabulation
      investigations may reveal increased mean cell volume and raised gamma-glutamyl
       transferase levels

Features of alcohol dependence include:

      a fixed daily routine of drinking in order to avoid withdrawal
      priority of drinking over other activities
      increased tolerance to alcohol
      repeated withdrawal symptoms such as tremor, sweating and agitation
       relief of withdrawal symptoms by further drinking
       subjective awareness of the compulsion to drink
       rapid relapse (reinstatement) if drinking is resumed after abstinence

Investigations:

None of the tests mentioned below may be positive in heavy drinkers. However, all the tests
described may be positive in other conditions and are not pathognomonic for alcoholism.

       gamma-glutamyl-transferase (normal value less than 40 i.u. per litre) - the levels of
        this enzyme are raised in about 80% of problem drinkers. The level of increase in
        levels of this enzyme are in relation to heaviness of drinking.
       mean corpuscular volume (MCV) - this value is raised in over half of patients with
        alcohol dependence. It is more commonly raised in women with alcohol dependence
        than men. The value of MCV will return to normal if there is abstinence for several
        weeks. Normal is 80 to 90 fl.
       abnormal ALT reflects hepatocellular damage. If the AST:ALT ratio is greater than 2
        then this is suggestive of alcohol damage.
       blood alcohol concentration - raised as a result of an isolated drinking episode and
        chronic abuse. However an individual who has a blood alcohol level above 80mg per
        100 ml - the legal limit for driving - and is not intoxicated is likely to be a chronic
        heavy drinker. Greater than 150mg per 100ml is practically diagnostic if measured
        under particular circumstances, for example in clinic. Unconsciousness occurs at levels
        over 300mg per 100ml.
       creatinine phosphokinase (normal less than 150 i.u. per litre) - raised in 50% of
        problem drinkers
       urate and fasting triglycerides raised in 50% of problem drinkers.


Management:

A third of problem drinkers return to normal drinking without a doctor's intervention.

A brief intervention model has been shown to be effective in reducing alcohol intake by 20% in
problem drinkers. The components of this approach include:

       assessing alcohol intake
       explanation of the effects of alcohol
       advice on reducing intake
       follow-up consultations

Groups therapy, alcoholics anonymous and longterm counselling may be helpful but have
never been subject to trials.

For some problem drinkers it may be best to advise abstinence. In patients where alcohol is
not causing personal or social problems then aiming for controlled intake may be acceptable

Withdrawal of alcohol in less severe cases of dependency may be managed at home. For the
first five days, the patient's temperature, pulse, blood pressure, hydration and level of
consciousness need to be assessed daily. If there is deterioration, delirium tremens may be
developing and the patient should then be admitted to a detoxification unit.

Daily visits by a district nurse or CPN may be needed for physical and mental state
assessment and to administer medication.
The support of family, friends and care workers is essential. Groups such as Alcoholics
Anonymous to support the patient, Al-Anon to support the spouse and Al-Ateen to support
teenage children may be useful.

Sedatives and short-term courses of treatment may be needed but should not be used for
longer than nine days because of the risk of addiction.

Psychological support has three main aims:

      maintenance of motivation:
          o building on interests and hobbies
          o new activities e.g. exercise classes

      prevention of relapse:
           o patients should keep alcohol diaries including the circumstances of any
              drinking
           o group therapy e.g. alcoholics anonymous
           o pharmacological prevention of relapse

      solving underlying problems:
           o problem solving techniques
           o marriage guidance
           o interpersonal psychotherapy

Treatment of serious alcohol withdrawal:

Drugs are required to replace alcohol during withdrawal in order to prevent delirium tremens
and fits:

      chlordiazepoxide
           o chlordiazepoxide is the drug of choice (1). Diazepam is an alternative
           o chlordiazepoxide is the preferred benzodiazepine for community-based
               detoxification in view of its long half-life, and also because there is less
               likelihood of 'diversion' into the illicit drug scene (2) - diazepam is often a drug
               of abuse
           o the following chlordiazepoxide regime is recommended (1) - though
               the dose level and length of treatment will depend on the severity of
               alcohol dependence and individual patient factors (e.g. weight, sex,
               liver function)

               Day 1 &2           20-30mg chlordiazepoxide QDS
               Day 3 & 4          15mg chlordiazepoxide QDS
               Day 5              10mg chlordiazepoxide QDS
               Day 6              10mg chlordiazepoxide BD
               Day 7              10mg chlordiazepoxide nocte


   

       dispensing should be daily, or involve the support of family members to
       prevent any risk of misuse or overdose. Confirm abstinence by checking for
       alcohol on the breath, or using a saliva test or breathalyser for three to four
       days
      if possible, see the patient daily for the first five days and again after
       detoxification has finished. These do not have to be long consultations but
       they will allow the early detection of complications and encourage the patient
       to continue. Usually there will be a noticeable improvement in the patient as
       the detoxification progresses
      where there is significant liver disease, diazepam and chlordiazepoxide
       metabolism is impaired, and it imay be necessary to consider a
       benzodiazepine that is not metabolised by the liver e.g. oxazepam

      chlormethiazole is recommended as a second-line drug in inpatients and is not
       recommended for outpatient detoxification

      haloperidol is the antipsychotic drug of choice:
           o haloperidol should be reserved for acute hallucinosis, it should be used
               cautiously and reviewed regularly
           o note that antipsychotic medication may increase the risk of seizures and is
               essentially indicated in the treatment of delirium tremens in patients who have
               a history of delusions or hallucinations during alcohol withdrawal - these
               patients should be referred to specialist services (2)

      confirmed or imminent acute Wernicke's encephalopathy or Korsakoff's psychosis
       requires treatment with a multivitamin preparation

      oral thiamine plus vitamin B and C supplements
           o in cases of mild-to-moderate alcohol dependence, oral thiamine (100mg three
                times daily) with vitamin B complex (one tablet three times daily) and ascorbic
                acid (500mg once daily) should provide adequate replacement (2)
           o if a patient is malnourished, or shows evidence of self-neglect and have
                symptoms of peripheral neuropathy, parental vitamin supplementation with
                Pabrinex im (vitamins B and C) for three to five days, followed by oral vitamin
                supplementation, is advised (2)
           o if features of Wernicke-Korsakoff syndrome - confusion, ataxia,
                ophthalmoplegia, nystagmus, memory disturbance, hypotension and
                hypothermia - then patients require specialist treatment with Pabrinex iv for
                five or more days until improvement is observed (2)

      withdrawal seizures usually respond to treatment with diazepam or chlormethiazole:
           o status epilepticus should be treated with intravenous diazepam, followed by
              intravenous chlormethiazole and thiamine
           o routine anticonvulsant medication should not be prescribed - patients with a
              history of alcohol-related seizures should be referred to specialist services for
              detoxification (2)


Complications:
GI:

These include:

      oesophagitis

      gastrointestinal haemorrhage:
           o Mallory Weiss syndrome
           o varices
           o gastritis
        pancreatitis

        diarrhoea:
             o watery diarrhoea - direct effect of alcohol
             o steatorrhoea - from chronic alcoholic pancreatitis

        alcoholic liver disease and associated complications

        carcinoma:
             o oesophagous
             o cardia of stomach
             o liver
             o pancreas

CV:

These include:

        dilated cardiomyopathy
        cardiac arrhythmias
        essential hypertension
        beri-beri heart disease / wet beri-beri

Neuro:

These include:

        "black outs" / alcoholic coma
        nutritional effects:
             o thiamine deficiency:
                       Wernicke's encephalopathy
                       Korsakoff's psychosis
             o niacin deficiency:
             o pellagra
        withdrawal:
             o "morning shakes"
             o tremor - arms, legs
             o delirium tremens
        seizures:
             o acute intoxication
             o alcohol withdrawal
             o hypoglycaemia
        cerebellar degeneration
        cerebral atrophy:
             o dementia
             o subdural haemorrhage
        alcoholic myopathy
        autonomic neuropathy
        Marchiafava-Bignamia syndrome - very rare, involving corpus callosum

Haemo:

These include:
        macrocytosis / macrocytic anaemia:
            o alcohol has direct toxic suppressive effect on bone marrow
            o dietary folate deficiency
            o iron deficiency due to blood loss
            o rarely, vitamin B12 deficiency due to chronic pancreatitis

        thrombocytopenia:
             o bone marrow suppression
             o hypersplenism

GU:

Men:

        impotence
        testicular atrophy

Women:

        amenorrhoea
        infertility
        spontaneous abortion
        foetal alcohol syndrome

Other:

These include:

        metabolic:
            o hyperuricaemia
            o hyperlipidaemia
            o hypoglycaemia
            o obesity

        bone:
             o   osteoporosis
             o   osteomalacia

        endocrine:
            o pseudo-Cushing's syndrome

        respiratory:
             o chest infections

Psych:

These include:

        depression:
             o depression may result from alcohol abuse
             o depressed patients may drink to improve their mood
        anxiety
         personality disturbance - for example, avoidance of responsibilities at home and at
          work
         memory impairment
         suicidal behaviour - higher suicide rate in alcoholics
         pathological jealousy
         alcohol hallucinosis

Social:

These include:

         marital and sexual difficulties
         family disruption
         child abuse
         employment difficulties
         financial difficulties
         increased risk of accidents - at home, at work, on the road
         tendency to crime
         homelessness

Screening: CAGE

Alcohol dependence is likely if the patient gives 2 or more positive answers:

         have you ever felt you should CUT down your drinking?

         have people ANNOYED you by criticising your drinking?

         have you ever felt bad or GUILTY about your drinking?

         have you ever had a drink first think in the morning to steady your nerves or get rid of
          a hangover (EYE- opener)?

Bernadt et al have claimed that the CAGE test (scores >=2) has a sensitivity of 93% and a
specificity of 76% for the identification of problem drinkers.

Screening: alcohol dependence criteria:

At least three of the following :

         alcohol often taken in larger amounts or over a longer period than the person intended

         persistent desired or one or more unsuccessful efforts to cut down or to control alcohol
          use

         a great deal of time spent in activities necessary to obtain alcohol, drink alcohol, or
          recover from the effects

         frequent intoxication or withdrawal symptoms when expected to fulfil major role
          obligations at work, school, or home, or when alcohol use is frequently hazardous
      important social, occupational, or recreational activities given up or reduced because
       of alcohol use

      continued drinking despite knowledge of having persistent or recurring social,
       psychological, or physical problem that is caused or exacerbated by alcohol use

      marked tolerance - need for markedly increased amounts of alcohol (ie at least 50%
       increase) in order to achieve intoxication or desired affect, or markedly diminished
       effect with continued use of the same amount

      characteristic alcohol withdrawal symptoms

      alcohol often taken to relieve withdrawal symptoms

NB. Some symptoms of the disturbance have persisted for at least 1 month, or have occurred
repeatedly over a longer period of time.

				
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