Dr.

Adel Al zayed
Kuwai t Uni vers i t y – medi cal col l ege
Alcohol Misuse


Background of alcohol and substance misuse



Alcohol Dependency Syndrome

Alcohol Intoxication

Alcohol withdrawal

Alcohol delirium

Alcohol persisting dementia

Alcohol persisting amnestic disorder

Alcohol psychotic disorders

Alcohol mood disorders

Alcohol anxiety disorders

Alcohol sexual dysfunction

Alcohol sleep disorder

Alcohol induced psychotic syndromes

Background

Alcohol is the most commonly abused drug


Consequences related to:

Pharmacology

Hazards inherent to route of admin

Dose and frequency of use

Personality of user
20-30% of males and 5-10% of f admissions were deemed
to be

“problem drinkers”

Alcohol d/o = for 10% (first) - 20% psychiatric admissions

DSM IV criteria met in 16% of males and 3% of females

Prevalence of alcohol related problems is linked to alcohol
consumed per capita

Rise in consumption since 1950@ 60%

Mortality rates from alcohol related cancers increasing over 10 yrs

Risk of cirrhosis increases along with increasing consumption starting at

6 units per day (f) and 8 units per day(m).

12 units/day risk increased 14 fold(m)

Admissions due to medical complications begins to rise at 21 units /week

CVA begins at 42 units/wk



Male Female
Hazardous drinking 21u/wk 14 u/wk
Safe use < “ < “

Intoxication

A transient condition following the administration of alcohol or other
psychoactive substance, resulting in disturbance in level of consciousness,
cognition, perception, affect or behaviour or other psychophysiological
functions and responses


Related to drug level(some exceptions)

Recovery is complete

Symptoms need not always reflect the primary actions of the substance. Effects of
substances such as cannabis+ hallucinogens may be unpredictable

Ddx. Acute head injury / hypoglycaemia / mixed substance abuse
Acute Intoxication(Alcohol)

 Initial action on the reticular formation t v t on
 L t r tox ts on ort l n uron s n r t on
( x l r t on x t m nt loqu t
m ml
 R u ps olo l n t v r n w t
su t v sup r or t n s ll
 Thinking superficial + slowed with poverty of associations + impaired judgement, reasoning, learning, conc
 Slowed motor control + reaction time  t x n n oor n t on
 mot ons o s l p t s n ss rr t l t n ost l t
or l r t m n t upp r n  om · ·
 l outs
 pup ls l t or onstr t n t n on r l x s w
 r ox l r t ons

Alcohol Dependency Syndrome
A cluster of physiological, behavioural, and cognitive
phenomena in which the use of a substance or a class of
substances takes on a much higher priority for a given
individual than other behaviours that had a higher value

+3 of
qDesire
qDifficulty controlling substance taking behaviour
q
A physiological withdrawal state when substance reduced
or d/c or use of the same substance to relieve or avoid
withdrawal symptoms (200-300g/day/yrs)
qTolerance
qNeglect of alternate pleasures
qPersistence despite harmful consequences


ADS : Edwards and Gross 1976

Stereotyped pattern of drinking

Prominence of drink seeking behaviour

Increased tolerance

Repeated withdrawl symptoms

Relief or avoidance of withdrawls by further
drinking

Subjective awareness of compulsion to drink

Rapid reinstatement after abstinence(within 72 hrs
if severely dependent)
14% lifetime prevalence
M:F 4:1

47% meet criteria for another d/o Odds Ratio
 Antisocial pd 21
 Drug dependence 11.2
 Mania 6.2
 Schizophrenia 4.0
 Panic d/o 2.4
 Major Depression 1.7

Onset: males late teens/20’s Insidious course: later for females, more likely
to drink alone and have higher rates of co-morbid depression, stronger
genetic predisposition and more physical complications
Higher in urban, divorced, separated, lowest in middle social groups

High risk groups: manufacture or sell alcohol,
commercial travellers, entertainers, doctors,
journalists


Permissive factors: job mobility, absence of
restraining structures/ supervision,
availability of alcohol



Aeitology: Multi factorial

Family stuudies: 7 fold increase in first degree rels

Twin Studies: 70%:43% for males…Prikens 91

47%:32% for females….Kendler 92
Adoption studies:Danish, Sweedish,US

sons of alcoholics 4 times more likely to have ADS

high rates of conduct d/o in male offspring of

alcoholics

ADS and anti-social pd are genetically independent



BIOCHEMISTRY
 DA: Alcohol stimulates Da release in nuclues accumbens. Increased DA
r v n

 5HT Alcohol potentiates effect of 5HT at 5HT3 receptors. Recent reports of 5HT
Agonists reducing craving


PSYCHOLOGICAL
 no evidence of an alcoholic personality

Modelling may explain familial association

Operant conditioning: Relief of withdrawl symptoms promotes further abuse


SOCIOCULTURAL

CNS Effects: Withdrawl state
A group of variable symptoms occurring on absolute or relative withdrawal
of a substance

Tremulousness, anxiety, irritability, dysphoria, retching, sweating, mood
change, hyperacusis, tinnitus, muscle cramps, sleep abnormalities,
perceptual distortions hallucinations(4-24 hrs)

Fits occur 12-36 hrs after d/c may occur up to 12 days

 5% dts
 34% tremulousness
 11% hallucinations = tremor
 2% a hallucinations
 12% fits
 3% Wernicke Korsakoff syndrome


EEG show slowing during intoxication,
normalisation,16-33 hours later the alpha
wave diminishes with random spike and
bursts of slow wave activity.


Alcohol r s s R
t r wl x ss o R


DETOXIFICATION
Treatment of minor withdrawls

Inpt v opd Rx.


Treat in hospital if previous hx. of DT’s or seizures, or suicidal or other
significant psychopathology

In hospital:
 Chlordiazepoxide (a benzodiazepine)

reducing dose eg initially 40 mg QID
 + Thiamine 300mg od
 Ensure hydration
 Titrate dose with symptoms
 Regular nursing obs
 Clonidine adrenergic blocker : useful
Delerium Tremens

Full syndrome of DT’s 3-4 days after d/c (risk begins
12u/day)..typically at night time


Hallucinations, +/- delusions, confusion, disorientation,
tremulousness, increased psychomotor activity,
fearfulness,signs of autonomic disturbance


NB. Remember infxn and trauma (present in 50%),
wernickes encephalopathy, metabolic disturbances,
hypoglycaemia, head injury
Treatment of Delerium Tremens

Prevention

Rx in hospital. Medical emergency

I/2 hrly temp, pr, bp, intake/output

Fluids(6 L/day of which 1.5L n saline)

Check mg and k and glucose

Sedation(up to 400mg /day of chlordiazepoxide)

High potency vitamin preparation

Phenytoin or carbamazepine if seizures
Wernickes Encephaolpathy
 ACUTE NEUROPSYCHIATRIC REACTION TO SEVERE THIAMINE DEFICIENC

 *Nystagmus, .....................................96%
 *Ataxia of gait …………………………....87%
 *Global confusionalstate..90%(disorientation, apathy and derangement of memory) +/-
confabulation
 *+/-Peripheral neuropathy ……………………48%

 Nutritional deficiency..84%, Liver d/o: 33%
 Rx.: Medical emergency Thiamine 50 mg im/parentrovite im/iv..if not respnoding check mg
 General mx. ie. Rx. infxn, electrolytes, dehydration
 Prognosis confusion clears:1-2 months,

50%84% amnseic syn
 Pathology degenerative changes: thalamus, hypothalamus, mamillary bodies, Hippocampus, 3 +4
th

ventricles
Korsakoff syndrome and Dementia

Korsakoff syndrome:
Inability to form new memories and retrorgade amnesia for
years
Confabulation ie. Apparent recollection of imaginary events
Perseveration of other functions and clear consciousness
Peripheral neuropathy
Only 20% improve with thiamine


Dementia
Mild cognitive deficits but reversible with abstinence
Females may be more at risk
Rare< 40 years
CT/MRI: ATROPHY

CNS
 Seizures
 Myopathy
 Optic atrophy
 Cerebellar degeneration
 Marchifava-Bignami disease
 ntr l ont n l nol s s

s tr
 Co-morbidities
 Suicide and DSH 56% of men and 23% of women who comit suicide are alcoholics…………….Kessel 1965
 Homicide
 Sexual difficulties

Respiratory

Cardiovascular

Gastrointestinal

Liver damage.. After 10 years of abuse .Cirrhosis 10% of alcoholics

Haematological

Neoplasm

FAS

Social/Occupation

Accidents: 80% of fatal car accidents involve alcohol/ Crime

Hallucinations
B9, transient, while person still drinking

Usually auditory

In the absence of confusion


Sensory disturbances eg tinnitus often reported b/f the
hallucinations develop eg tinnitus


Withdrawl of alcohol usually results in resolution of
symptoms………………………………...Bendetti


Aloholic hallucinosis ?schizophrenia?organic psychosis?
Thiamine deficiency
Othello Syndrome: Pathological Jealousy

Delusions of infidelity
Alcoholic Convulsions


within 12-48 hrs of d/c or reduction of alcohol


Usually grand mal


Several years of addiction


Not a latent epileptic process brought to life

Alcohol abuse
Difficult pt often evasive/rationalise alcohol intake. High index
of suspicion warranted

CAGE Questionnaire

Use a problem orientated approach

Ask about last 7/7 activities + amt. of alcohol consumed

Lab’s: mcv, ggt

Involve family realtionship is an important predictor of o/c
Goal orientated treatment plan
Alcohol Dependency Treatment
Detox

Aversive treatment: Disulfiram “antabuse” 200-
400mg/day…consumption of alcohol 
t r lus n
l our r t n n
pot ns on… ·

sfx: tiredness, headache, halitosis, reduced libido, dermatitis,
neuritis,and confusional states

CI: suicidal pt, psychosis, heart disease, hypotensive drugs,
intoxicated

can be disipensed by partner as pt of a contract or by (proven
benefit.) an employer

Acamprosate ”Camparal EC” GABA analogue….reduces
craving

Specialist Services

Pyschosocial intervention:
Inpt for 6-8 weeks eg..Tabor Lodge, Matt Talbot House.

No clear adv of inpt. over opd mx.

OPD Mx.Counselling services eg. Arbour House St. Finbars Hospital
Social skills training: id. social cues, teach skills eg refuse
drinks, buying non alcoholic drinks, avoid rounds, go to pub
late, being firm, learning new ways to cope
Group therapy…rationalisations and misperceptions are
revealed
Conjoint and family therapy ..enable pts of the family to have
their views heard in a controlled manner..

AA and ALAnon
Outcome
Dependent upon social and marital stability

Severity of dependency

Involvement of spouse, community reinforcement strategies

Social skill training and follow up

Poor if: brain damage/ comorbid psych illness esp anti-social
pd/criminal hx./low IQ/poor support/low motivation

10 year follow up: 61% in remission for 3 years