ALCOHOL USE DISORDer presentation by pg stdent

Good presentation can help pgs

1. ALCOHOL USE DISORDER GUIDE : DR. PRAVEEN KUSUBI STUDENT : DR. YERRI KUMAR

2. Contents Definitions Alcohol use disorder criteria Effects of alcohol on various organ systems Alcohol withdrawl Management of alcohol dependence Prevention and relapse

3. Definitions ALCOHOL INTOXICATION : Transient syndrome due to recent substance ingestion that produces clinically significant psychological and physical impairement . changes disappear when substance is eliminated from body psychological impairment- varies on individual

4. Definitions 1.HARMFUL USE : icd-10 Maladaptive patterns of alcohol use that impairs health in a broad sense 2. ALCOHOL DEPENDANCE: icd-10 State in which patient experience pharmacological tolerance, withdrawl , sense of compulsion to take substance and neglect alternate goals and interests

5. Definitions AT-RISK DRINKING a. men > 14 drinks/week or >4 drinks per a day b. women >7drinks/week or > 3 drinks per for day 2. ALCOHOL BINGE: pattern of drinking alcohol that brings blood alcohol conc. to >0.08g/dl. It roughly corresponds to 5 or more drinks in male or 4 or more in females in less than 2 hour

6. Definitions TOLERANCE: repeated administration of a drug produces decreased effect (or) increased doses required to produce same effect. TYPES 1.PHARMACOLOGICAL /METABOLIC 2.CELLULAR / PHARMACODYNAMIC 3.LEARNED/ BEHAVIOURAL

7. Alcohol Dependance : 3 or more in same year Strong desire or sense of compulsion to take Difficiult in controlling substance taking behavioiur Withdrawl state Tolerance Progressive neglect of alternate pleasures and intresets Persisting with substance use despite clear evidence of harmful consequence

8. Alcohol use disorder: DSM-5 Repeated alcohol related difficulties in atleast 2 of 11 life areas that cluster in same 12month period Medical condition involving frequent or heavy alcohol usage DSM-5 abandoned stigmatizing terms – addict, dependence, abuse Introduced ALCOHOL USE DISORDER- spectrum of conditions involving mild to heavy drinking, dependence, withdrawl .

9. Criteria: ALCOHOL USE DISORDER 1.Drinking resulting in recurrent failure to fulfil role obligations 2.Recurrent drinking in hazardous situation 3.Continuous drinking despite alcohol related social or interpersonal problem 4. Tolerance 5. Withdrawl or substance use for relief/avoidance of withdrawl 6.Drinking in large amount or larger than intended

10. CRITERIA 7. Persistence desire or unsuccessful attempts to reduce drinking 8. Great deal of time spent obtaining,using recovering from alcohol 9.Important activities given up reduced 10. Continued drinking despite knowledge of physical, psychological problems caused by alcohol 11.Alcohol craving

11. Criteria Two or more criteria occurring in same 12 month period must be present Mild AUD : 2-3 Criteria Moderate AUD : 4-5 items Severe AUD : 6 or more

12. EPIDEMOLOGY Prevalance in india : 19% Legal age for alcohol consumption in Karnataka : 21 years Factors determining alcohol use: class, caste and ethnicity Alcohol related deaths :2.6 lakhs every year 1 lakh deaths that occur on Indian roads are indirectly related to alcohol use Highest alcohol use among age group: 40 to 64

13. EPIDEMOLOGY

14. EPIDEMOLOGY

15. Alcohol Content Of Different Beverages Beverage Alcohol content Units of alcohol Ordinary beer 3% 2 per pint Strong beer 5-7% 5 per pint Wine 8-10% 7 per bottle Spirits (whisky, gin, brandy, vodka) 32-40% 30 per bottle

16. Etiology : various theories explaining alcoholism Psychological theory Psychodynamic theory Behavioural theory Sociocultural theory Genetic theory Childhood history

17. Psychological theory Reduces tension, increase feelings of power Decrease psychological pain Decrease nervousness Increased feeling of well being helps to cope with day to day stresses of life

18. Theories PSYCHODYNAMIC THEORY: anxiety lowering effects, decrease unconscious stress level BEHAVIOURAL THEORY : expectations about rewarding effects subsequent reinforcement after alcohol intake CHILDHOOD HISTORY: ADHD, conduct disorder, anti social personality

19. Theories SOCIOCULTURAL THEORY: cultural attitudes personal responsibilities GENETIC THEORY: close family members – 4 fold increase identical twin – increased risk adopted children of alcoholic people

20. Pharmacology Blood levels expressed as mg/dl (or) g/dl Absorbed from mucous membranes of mouth, esophagus , stomach, small gut and colon Rate of absorption increased by: a. rapid gastric emptying b. abscene of proteins, fats and carbohydrates c.diluted to modest concentration

21. ETHANOL ACETALDEHYDE ACETALDEHYDE ACETYL CoA ACETATE ALCOHOL DEHYDROGENASE 80% MEOS 20% ALDEHYDE DEHYDROGENASE FATTY ACIDS CO2 + WATER CITRIC ACID CYCLE

22. Levels of impairment at different alcohol levels 20–30mg/dl : Slowed motor performance and decreased thinking ability 30–80 mg/dl : Increases in motor and cognitive problems 80–200mg/dl : Increases in incoordination and judgment errors Mood lability Deterioration in cognition 200–300mg/dl : Nystagmus, marked slurring of speech, and alcoholic blackouts >300mg/ dl :Impaired vital signs and possible death

23. EFFECTS OF ALCOHOL ON BRAIN Acts on all neurotransmitter system GABA enhancememt : anti convulsant, anxiolytic, sleep inducing, muscle relaxant Inhibit post synaptic excitatory NMDA receptors Increases Dopamine levels in ventral tegmentum – continued alcohol use, craving and relapse Also acts on opioid , serotinergic and cannabinol receptors

24. Alcohol addiction C hronic relapsing disorder associated with compulsive alcohol drinking, the loss of control over intake, and the emergence of a negative emotional state when alcohol is no longer available 3 STAGES: Binge/Intoxication Stage: reward, incentive salience, and pathological habits. Negative Affect/Withdrawal Stage: reward deficits and stress surfeit  Preoccupation/Anticipation Stage: craving, impulsivity, and executive function

25. Effects of ethanol on organ systems 1.CNS ACUTE EFFECTS : Black outs : temporary anterograde amnesia Disturbed sleep: a.sleep stages altered b. decreased REM and deep sleep c. disturbed dreams 3. Exacerbate sleep apnea

26. CNS : Acute effects 4. Impaired judgement and co-ordination 5. Hangover syndrome : headache, nausea , vomiting, thrist and fatigue following day Responsible for missed time and cognitive deficit at work

27. CVS: Acute effects Decrease myocardial contractility Increase peripheral vasodilation Mild decrease in BP

28. Gastrointestinal system ACUTE EFFECTS Esophageal varices Mallory Weiss tears Alcoholic gastritis

29. PANCREAS : ACUTE PANCREATITIS 4 times increased risk of pancreatitis Quantity and duration of alcohol consumption Present with severe abdominal pain, nausea, vomiting, fever and hypotension Life threatening condition

30. CNS : Chronic effects Periphreal neuropathy: 10% of alcoholics - bilateral limb numbness,paresthesia,tingling - similar to diabetes 2. Cerebellar degeneration or atrophy - progressive unsteady gait and stance - nystagmus - imaging : vermis atrophy

31. CNS : Chronic effects 3.Wernicke’s encephalopathy: opthalmoparesis , ataxia and encephalopathy 4. Korsakoff psychosis: retrograde and anterograde amnesia 5. cognitive problems : mild to moderate memory impairment to severe dementia

32. WERNICKE’S ENCEPHALOPATHY T halamus, hippocampus, hypothalamus, and cerebellum – mostly affected These areas contribute to a wide range of functions such as vision, movement, language, sleep, memory, and moti vation  some symptoms of Wernicke’s disease such as muscle and vision problems are reversible with thiamine treatment, other symptoms may respond more slowly or may not be completely reversible. Without prompt treatment, Wernicke’s disease can progress to Korsakoff’s psychosis, which is not reversible.

33. Symptoms of Wernicke’s encephalopathy Confusion  Lack of energy, hypothermia, low blood pressure, or coma Lack of muscle coordination that can affect posture and balance and can lead to tremors (i.e., involuntary movements in one or more parts of the body)   Vision problems such as abnormal eye movements (e.g., back and forth movements called nystagmus), double vision, misaligned or crossed eyes, and eyelid drooping

34. Korsakoff psychosis :symptoms Potentially severe, irreversible memory impairments, including problems forming new memories (called anterograde amnesia) and recalling memories 2 Making up inaccurate stories about events (i.e., confabulation) or remembering events incorrectly Experiencing hallucinations (i.e., seeing or hearing things that are not really there) Repetitious speech and actions 1,2 Problems with decision making as well as planning, organizing, and completing tasks 2 Lack of motivation and emotional apathy 2

35. CVS : Chronic effects Hypertension Alcoholoic cardiomyopathy Supraventricular arrhythymia Most common cause of non-ischemic cardiomyopathy Increased risk of heart failure, MI, Atrial fibrillation

36. Liver Factors : quantity , duration of alcohol, female gender and malnutrition Manifestation: acute fatty liver, alcoholic hepatits and cirrhosis Fatty liver: - asymptomatic or non specific abdominal discomfort - improves with abstinence

37. LIVER ALCOHOLIC HEPATITIS : - Asymptomatic condition identified with abnormal liver enzymes (or) - Acute episode with abdominal pain, nausea, vomiting and fever High levels of AST , ALT ( AST>ALT) And GGT Improves with abstinence and supportive care

38. LIVER ALCOHOLIC CIRRHOSIS : - Major cause of death - jaundice, edema , coagulopathy and encephalopathy - gastrointestinal bleed from esophageal varices Conservative treatment Liver transplant

39. Gastrointestinal system Peptic ulcer disease Risk of squamous cell cancer of esophagus Present with dysphagia, chest pain and GI blood loss and wt. loss

40. CHRONIC PANCREATITIS Recurrent episodes of acute pancreatitis Present with chronic abdominal pain, malabsorption, weight loss and malnutrition Difficult to treat

41. HEMATOPOIETIC SYSTEM Chronic alcoholism : ANEMIA Causes: 1. GI blood loss due to varices, Mallory Weiss tear, alcoholic gastritis 2. iron deficiency 3. direct toxic effect on bone marrow 4.micronutrient deficiency: vit b12, copper 5. hypersplenism

42. HEMATOPOIETIC SYSTEM 1. Thrombocytopenia : supress megakaryocyte production - sensitive to abstinence , normal levels within 5 to 7 days of abstinence. 2. Decreased function , production of WBC. : Deranged cellular and humoral immunity - High risk for infectious disease like TB, pneumonia

43. CANCER Amount of alcohol exposure that increases cancer risk may vary and there is no “safe levels” of alcohol consumption Co occurance of alcohol and smoking increases risk Most common: upper digestive, respiratory, liver malignant neoplasm Specific with alcohol: squamous cell ca of esophagus and head & neck tumors

44. CANCER Breast Prostate Pancreas Lung Colon cervix

45. GENITOURINARY SYSTEM Adolescence drinking: affect normal sexual development Chronic alcoholism in men: causes infertility a. irreversible testicular atrophy b. increase sexual drive but decrease erectile capacity C. shrinkage of seminiferous tubules D. decreased ejaculate volume and low sperm count

46. GENITOURINARY SYSTEM CHRONIC ALCOHOLISM IN WOMEN Amenorrhea Decrease ovarian size and reserve Infertility Increased risk of spontaneous abortion Heavy drinking during pregnancy : FETAL ALCOHOL SPECTRUM DISORDER (FASD)

47. FETAL ALCOHOL SYNDROME 5% Children born to heavy drinking mother Facial changes with epicanthal eye fold, poorly formed ear concha Microcephaly with mental retardation Aberrant palmar crease and limitation of joint movement ASD or VSD Small teeth with defective enamel

48. Psychiatric manifestation Anxiety Suicide Alcohol induced psychotic disorder 2/3 rd of individual with alcohol use disorder meet other criteria of another psychiatric syndrome Depression

49. Alcohol withdrawl Sudden decrease or cessation in alcohol consumption Symptoms are opposite to those produced by intoxication Clinical features Tremors: Most common, earliest within 8 hour of stopping Agitation and anxiety Autonomic nervous system hyperactivity : increase in pulse, respiratory rate, sweating and body temperature insomnia , Visual and auditory hallucination

50. Alcohol withdrawl syndrome 2% alcoholics experience withdrawl seizures ALCOHOL WITHDRAWL SEIZURES Grand mal type Occur within 12 to 24hour after reduction or stoppage No need of anti epileptics Benzodiazepenes are used

51. Alcohol withdrawl syndrome DELIRIUM TREMENS Most severe manifestation c/f: disorientation, confusion, hallucination,diaphoresis,fever and tachycardia Triad : clouding of consciousness, hallucinations and illusions and tremors Begins 2 to 4 days after abstinence Lasts for 1-5 days Inpatient management, if untreated mortality upto 20%

52. MANAGEMENT OF DELIRIUM TREMENS IV fluids for hydration BZD’s : mainstay- lorazepam 2mg or diazepam 10mg iv/ im Repeated doses till symptoms clear Doses tapered in 5-7 days THIAMINE : 200-300mg IM daily for 3-5days or orally three times a day Monitor vitals, look for neurological deficit, put on high calorie and high carbohydrate diet

53. Others ALCOHOLIC MYOPATHY - 2/3 rd develop skeletal muscle problems - this condition improves but not fully remits with abstinence -changes in calcium metabolism, lower bone density, increased risk for fractures.

54. Diagnosis of alcohol problems History Physical examination Laboratory studies Prevention and treatment

55. History Ask all patients about current and past use Detailed history regarding quantity and frequency of alcohol use Standardized questionnaire Assess specific areas in suspected or known problem drinkers

56. Step 1 Do you drink alcohol – ever or currently No- life time abstainers, requires no further questioning If yes,- proceed through next 3 questions

57. Step 2 Detailed history regarding quantity and frequency , type of alcohol Quantity to be determined- how much do you drink on typical day Do you drink more than usual amount For identifying binge drinking Quantity for at risk drinking Frequency for identifying daily drinkers from non daily drinkers

58. Step 3 Standardized screening instruments CAGE questionnaire C – cut down A- annoyed by others criticism for drinking behaviour G- felt guilt E- eye opener – drink first thing in the morning Sensitivity 47-97% , specificity 70-97% when cutoff of score 2 is used

59. AUDIT questionnaire Ten questions Scores given for each answer score intervetion 8-15 Brief intervention based on risk factors 16-19 Brief intervention regular monitoring 20-40 Diagnostic assessment, detoxification and other specific treatments

60. Step 4 Assess specific areas in suspected or known problem drinkers Criteria for alcohol abuse and dependence Evidence of medical and psychiatric problems Evidence of behavioural or social problems Use of other substances

61. Physical examination Detailed physical examination Pallor, icterus, edema Cvs : pulse, blood pressure, apical impulse Git : abdominal distension, hepatomegaly, signs of chronic liver failure, splenomegaly Cns : consciousness, orientation, memory, sensory system examination, reflexes, co-ordination

62. Laboratory finding Cbc : hb , macrocytic anemia Lft : total bilirubin, direct bilirubin, AST, ALT, Prothrombin time GGT Carbohydrate deficient transferrin Usg , MRI

63. LABORATORY DIAGNOSIS Parameter Normal value Value in chronic alcoholic Serum GGT 4-30U/L >30U/L MCV 80-95MCM >100MCM Carbohydrate deficient transferrin >2.6% >1/3% OF TOTAL TRANSFERRIN CONC. AST & ALT <40U/L AST>ALT, >40 (LESS THAN 400)

64. Prevention and treatment TREATMENT OF AT RISK DRINKERS: Counselling strategy Motivational techniques Feedback about the problems with alcohol use Discussion of adverse effects of alcohol Setting recommended drinking limits

65. Treatment of alcohol use disorder In patient treatment for severe cases Specific counselling programs Pharmacologic therapy Management for alcohol withdrawl Prevention of relapse

66. Management of Alcohol withdrawl Mild to moderate – OPD basis and close up Moderate to severe withdrawl – inpatient basis Hypertension Tremors History of severe withdrawl in the past like delirium tremens History of alcohol withdrawl seizures

67. Goals of medical management of alcohol withdrawl Minimize the severity of alcohol withdrawl related symptoms Prevent specific withdrawl related complications Delirium tremens Seizures 3. Provide referral for relapse prevention treatment

68. Medications in alcohol withdrawl Benzodiazepines CHLORDIAZEPOXIDE : 25-100MG 4-6 TH HOURLY DIAZEPAM : 5-10MG PO/IV/IM 6-8 TH HOURLY LORAZEPAM : 1-4MG PO/IV/IM 6-8 TH HOURLY OXAZEPAM: 15-30MG PO/IV/IM 4-8 TH HOURLY

69. Medications in alcohol withdrawl 2. Beta blockers Atenolol Propranolol 3. Alpha agonists Clonidine 4.Anti epileptic carbamazepine

70. MAINTAINING ABSTINENCE & REHABILITAION PHARMACOLOGICAL TREATMENT Disulfiram Acamprosate Naltrexone Others : SSRI Topiramate Baclofen PSYCHOSOCIAL INTERVENTIONS Brief intervention Extended interventions Group therapy Family therapy Self help groups

71. Prevention of relapse DISULFIRAM: 125-500MG PO daily NALTREXONE: 50mg PO daily 380mg IM every 4week 3. ACAMPROSATE : 666MG PO three times a day