Alcohol abuse
• Consumption of alcohol at a level to cause physical, psychiatric a/o social harm
Binge drinking
drinking over 2x recommended level of alcohol per day in one session
Harmful alcohol use
drinking above safe levels w/ evidence of alcohol-related problems
Alcohol dependence syndrome
- 25% M and 15% F drink over recommended level in UK
* Alcohol dependence: 4% (16-65)
Factors involved in and leading to dependence
Biogical
- Genetics (variation sn enzymes that metabolise drugs); neurochemical (abnormalities in Do, GABA, opioid systems)
Environmental
- Peer pressure, life stressorss, parental drug abuse, personal vulnerability (e.g. lack of resources to cope w/ stressors
Takes substance
- Cost, availability, effects of drug itself, route
+ve reinforcement
- Psychosocial reinforcement (peers or pleasurable effects of drugs)
- Biological reinforcement (activates dopaminergic mesolimbic reward pathways)
Dependence
+ve reinforcement over time –> dependence
RFs alcohol dependence
Male (increased metabolism → therefore can have higher quantities)
Younger adults
Lack of facial flushing
Antisocial behaviour
Genetics
Life stressors (E.g. divorce, unemployment…)
Lower socioeconomic groups
Certain occupations (e.g. Dr: stress, freedom from supervision, reluctance to seek help if there are problems)
Pathophysiology alcohol actions on CNS
- Enhancement of GABA-A transmission (anxiolytic effects)
- Inhibition of NMDA-mediated glutaminergic transmission (amnesic effects)
- Release of dopamine in mesolimbic system (euphoriant + ‘reward’ effects)
Pathophysiology development of dependence
- Sensitisation of dopaminergic pathway (mesolimbic system)
- Down-regulation of inhibitory GABA receptors + up-regulation of excitatory glutamate receptors → when alcohol is withdrawn there is hyper-excitability
CFs alcohol intoxication
- Slurred speech, labile affect, impaired judgement, poor co-ordination
- Severe cases: hypoglycaemia, stupor, coma
CFs alcohol dependence mnemonic
SAW DRINk
- Subjective awareness of compulsion to drink
- Avoidance or relief of withdrawal symptoms by further drinking
- Withdrawal symptoms
- Drink-seeking behaviour predominates
- Reinstatement of drinking behaviour after abstinence
- Increased tolerance to alcohol (requires more for same desired effect)
- Narrowing of drinking repertoire (i.e. fixed times for drinking, same drink…) → important to ask in Hx about pattern of drinking
CFs alcohol withdrawal
- Malaise, tremor, N+V, insomnia, transient hallucinations, autonomic hyperactivity, seizures
- Delirium tremens (the severe end-spectrum of withdrawal)
DDx alcohol dependence
- Psychiatric disorders: psychosis, mood disorders, anxiety disorders, delirium
- Medical disorders: head injury, cerebral tumour, CVA
Ix alcohol dependence
- Bloods: blood alcohol level, FBC, U+Es, LFTs (+GGT), Blood alcohol concentrarion, MCV (^), vitamin B12/Folate/TFTs (alternative causes of ^ MCV), amylase (pancreatitis), hepatitis serology, glucose (hypoglycaemia)
- Alcohol questionnaires: e.g. AUDIT
- CT head (if head injury suspected)
- ECG (arrhythmias)
- Blood tests to screen for alcohol dependence: RBC MCV, GGT, Carbohydrate deficient transferrin (all raised)
detox drugs
acamprosate or oral naltrexone
alcohol dependence driving
must inform dvla themselves
complications alcohol dependence - acute
Acute toxicity → clouding of consciousness, coma, risk of aspiration, hypoglycaemia, AKI
medical chronic affects of alcohol dependence
Hepatic
• Alcoholic liver disease (Fatty liver → alcoholic hepatitis → cirrhosis)
• Hepatocellular carcinoma
GI
• Gastritis/PUD, oesophageal varices, chronic pancreatitis, oesophageal carcinoma, mallory-weiss tear, stomach cancer
CV
• HTN, cardiomyopathy, arrhythmias (esp. AF), CVA
Respiratory
• Tuberculosis
• Pneumonia (Klebsiella streptococcal)
Haematological
• Anaemia, thrombocytopaenia
Neurological
• Seizures, peripheral neuropathy, cerebellar degeneration, Wernicke’s Encephalopathy (→ Korsakoff’s psychosis/encephalopathy), head injury (secondary to falls)
Obstetrics
• Foetal alcohol syndrome
psychological affects of alcohol dependence
- Morbid jealousy
- Self-harm and suicide
- Mood disorders
- Anxiety disorders
- Alcohol-related dementia
- Alcoholic hallucinosis
- Delirium tremens
social affects of alcohol dependence
- Domestic violence
- Drink driving
- Employment difficulties
- Financial problems
- Homelessness
- Accidents (RTA)
- Relationship problems
- Crime + violence
prevention of alcoholism
- ^ taxation
- Restricting advertising + sales
- More education in schools
