Alcohol Dependence

Question 1

What is IAPT?

Answer 1

• Improving Access to Psychological Therapies
• IAPT services provide evidence-based psychological therapies to people with anxiety disorders and depression
• Low intensity IAPT: individuals with mild to moderate levels of anxiety +/or depression
• High intensity: individuals with moderate to severe anxiety +/or depression +/or other mental illnesses.

Question 2

What is the action of chlordiazepoxide?

Answer 2

Type of benzodiazepine which treats symptoms of alcohol withdrawal

Question 3

What is the action of thiamine?

Answer 3

Used to prevent Wernicke-Korsakoff (B1) syndrome due to low levels of thiamine.

Question 4

What is the action of disulfiram (antabuse)?

Answer 4

Causes an acute reaction when alcohol is consumed in conjunction and thus minimises ongoing alcohol consumption.

Question 5

What is the action of naltrexone?

Answer 5

Blocks opioid receptors and used to treat opioid and alcohol addiction, reduces desire to drink.

Question 6

What is the action of acamprosate (Campral)?

Answer 6

Reduces desire to drink alcohol

Question 7

What is the action of folic acid in alcohol dependence?

Answer 7

Alcohol affects the ability to absorb folate and also increases folate in the urine. Increasing folate improves the health of alcoholics especially during withdrawal.

Question 8

What is the mechanism behind alcohol withdrawal?

Answer 8

• Chronic alcohol consumption increases GABA mediated inhibition in CNS and inhibits NMDA-type glutamate receptors
• Alcohol withdrawal thought to lead to opposite (decreased inhibitory GABA and increased NMDA glutamate release)
• Glutamate is an excitatory neurotransmitter

Question 9

What are the symptoms of alcohol withdrawal?

Answer 9

• Symptoms start at 6-12hrs: tremor, sweating, tachycardia, anxiety, disturbed sleep
• Mild: HTN, tachycardia, anorexia, anxiety, emotional instability, insomnia, irritability, diaphoresis, headache and fine tremor
• Moderate: worsening mild symptoms, agitation, coarse tremor
• Severe/delirium tremens: worsening moderate symptoms plus confusion/delirium, generalised TC seizures, auditory/visual/tactile hallucinations, hypothermia subsequent to psychomotor agitation

Question 10

What are the timings of more severe alcohol withdrawal symptoms?

Answer 10

• Severe withdrawal symptoms occur >24hrs and usually peak at 48hrs
• ~36hrs: seizures
• 48-72hrs: delirium tremens - coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia

Question 11

What is the management of alcohol withdrawal?

Answer 11

• Patient should keep drinking until detox is started, GP should prescribe folate and thiamine supplements
• Patients with a history of complex withdrawals i.e. DT seizures, blackouts - admit to hospital until stable
• 1st line: benzodiazepines e.g. chlordiazepoxide, typically given as part of a reducing dose regime - lorazepam may be better if hepatic failure
• Carbamazepine effective in treating
• Detox should only be done by community alcohol service to monitor patient safely and prevent further withdrawals
• CBT
• Sometimes antidepressants