alcohol abuse

Slide 1

Alcohol Abuse

Dr Amit Gupta MD Psychiatry

Gupta Hospital, Power house road, Bathinda

HISTORY OF ALCOHOLDiscovery of late Stone age jugs suggest that intentionally fermented beverages existed at least as early as the Neolithic period (cir. 10,000 BC)Babylonians regularly used both beer and wine as offerings to their gods. Around 1750 BC, the famous Code of Hammurabi devoted attention to alcohol. Although it was not a crime, the Babylonians were critical of drunkenness.1/24/2017Dr Amit Gupta MD Psychiatry2

HISTORY OF ALCOHOL

.Alcoholic beverages were consumed in INDUS VALLEY CIVILIZATIONThese beverages were in use between 3000 BC - 2000 The Hindu Ayurvedic texts describe both the beneficent uses of alcoholic beverages and the consequences of intoxication and alcoholic diseases. Most of the peoples in India and China, have continued, throughout, to ferment a portion of their crops and nourish themselves with the alcoholic product.1/24/2017Dr Amit Gupta MD Psychiatry3

.

1/24/2017Dr Amit Gupta MD Psychiatry4The ancient Egyptians made at least 17 types of beer and at least 24 varieties of wine.The earliest evidence of alcohol in what is now China are jars from Jaihu which date to about 7000BC.

What is alcohol ?

Ethyl alcohol - for which the more scientific name is ethanol - is the substance that we find in beverages.

Formed through fermentation of a variety of products including grain such as corn, potato mashes, fruit juices, and beet and cane sugar molasses1/24/2017Dr Amit Gupta MD Psychiatry5

Alcohol abuse is associated with many accidents, fights, driving offenses and unprotected sex.It is responsible in the world for 1.8 million deaths and results in disability in 58.3 million people. About 40 percent of these have alcohol related neuropsychiatric disorders.Alcohol consumption is estimated to cause from 20% to 50% of cirrhosis of the liver, epilepsy, poisonings, road traffic accidents, violence and several types of cancer.

Kerala led the states in terms of consumption followed by Maharashtra & Punjab. Over 11% of the population in India indulged in heavy or binge-drinking. The global figure stood at 16% A global study has found that alcohol consumption in India has risen by 55 % over a period of 20 yrs. More worryingly, the young are getting initiated to alcohol much earlier, while more women are indulging in hazardous and binge drinkingOne Indian dies every 96 minutes due to alcohol consumption- The Indian Express

1/24/2017Dr Amit Gupta MD Psychiatry8

Punjab has consumed liquor worth Rs 35,000 cr in last decade: RTIreply12 bottles of liquor for every Punjabi in 2014-15

The Tribune Chandigarh, March 15The Punjab Cabinet today approved the Excise Policy for the year 2016-17 by implementing which the state government expects to collect Rs 5,440 crore as against Rs 5,040 crore in current year, an increase of about Rs 400 crore1/24/2017Dr Amit Gupta MD Psychiatry9

Making of Ghar di shrab Home made liquor in rural Punjab1/24/2017Dr Amit Gupta MD Psychiatry10

World map showing alcohol per capita consumptionWorldwide consumptionThe report stated that 38.3% of the global population consumed alcohol. On an average, an individual over 15 years of age consumed 6.2 liters of alcohol annually. 1/24/2017Dr Amit Gupta MD Psychiatry11

IntroductionThe term First used by Magnus Huss, a Swedish Public Health Authority, in 1849, the word Alcoholism was quickly adopted by many other languages, with only minor variation.1/24/2017Dr Amit Gupta MD Psychiatry12

Recognizing the Stages of Alcoholism: The Jellinek Curve

E. Morton Jellinekwas a biostatistician, physiologist, and an alcoholism researcher- the man whose research provided the foundations for the Curve.Jellinek coined the expression the disease concept of Alcoholism and significantly accelerated the movement towards the medicalization of drunkenness and alcohol habituation.


Jellineks1960 book identified five types of alcoholism.1/24/2017Dr Amit Gupta MD Psychiatry14Alpha alcoholism: the earliest stage, purely psychological continual dependence of alcohol to relieve bodily or emotional pain. "problem drinker", drinking creates social & personal problems. These people can stop if they want to; thus, argued Jellinek, they have not lost control, do not have a "disease".Beta alcoholism: polyneuropathy, or cirrhosis liver without physical or psychological dependence. heavy drinkers that drink a lot, almost daily. Do not have physical addiction or withdrawal symptoms. This group do not have a "disease".Gamma alcoholism: acquired tissue tolerance, physical dependence, and loss of control. alcoholic, who is out of control, by Jellinek's classification, has a "disease".Delta alcoholism: as in Gamma alcoholism, but with inability to abstain, instead of loss of control.Epsilon alcoholism: the most advanced stage of the disease, manifesting as dipsomania, or periodic alcoholism.

Jellinek Curves best purpose may be as a way for people to understand their own struggles with addiction and not as a diagnostic tool. Its a learning tool. Its a visual and its a way that people can kind of normalize (in the sense of) this is what happens to some people.'Contentment in Soberiety,Increasing toleranceEmotional stability, Self careStable friends , Economic stability 1/24/2017Dr Amit Gupta MD Psychiatry15

Progressive phaseCrucial PhaseChronic PhaseRehabilitation PhaseRecovery PhaseDefeat admittedObsessive drinkingRelief drinkingtoleranceEfforts to control failFamily &friends avoidedNeglects foodTremors, physical problemsGuiltBlackoutsStops drinkingNew hopeRight thinking

Alcohol abuseAlcohol abuse is defined as repetitive problems with alcohol in any one of four life areassocialinterpersonalLegalOccupationalrepeated use in hazardous situations such as driving while intoxicated in an individual who is not alcohol dependent. 1/24/2017Dr Amit Gupta MD Psychiatry16

Alcohol Use Disorder DSM-5 312.9 (F91.9)According to the DSM-5, the symptoms of alcohol use disorder include a combination of craving, physical dependence, an increasing tolerance for alcohol and loss of control. .

Etiological Factors: Biological : Genetic vulnerability -most replicated Association and linkage studies genes encoding proteins involved in alcohol metabolism (ADH1B*2 & ADH1C*2 alleles) chromosome 4q and in the rewarding circuits, including dopamine (dopamine D2 receptor, DRD2 gene) allele A1 at the DRD2 locus on chromosome 11 & dopamine transporter gene DAT1) and GABA neurotransmitter biological pathways, (GABRA2, GABRA6 gene) chromosome 4q


.single nucleotide polymorphism in the hTAS2R16 gene (codes for a bitter receptor) located on the 7q chromosomal region, is associated with less sensitivity to bitter-taste Findings consistent with previous investigations of the relationship between taste perception and alcohol dependence.

Another candidate gene in the 7q locus is the CHRM2 gene. It codes for a Cholinergic muscarinic 2 receptor and shows significant association with alcohol dependence1/24/2017Dr Amit Gupta MD Psychiatry18

Candidate Genes Alcohol Metabolism alcohol dehydrogenase (ADH) gene The chromosome 4q region surrounding the (ADH) gene was linked in a genome-wide scan with a phenotype associated with alcohol dependence .. ADH1B*2 and ADH1C*2 alleles, and confer an increase in alcohol degradation rateADH1B*2 is common among Asians , is associated with a diminution in alcohol consumptionADH1C*2 has protective effects on liver cirrhosis and alcohol chronic pancreatitis , an is also associated with a lower rate in alcohol dependence among Asians.


Etiological Factors: Psychological

Curiosity Early initiation of alcohol & tobaccoPoor impulse controlLow self-esteem & Poor stress management skillsChildhood trauma / loss & Psychological distress


Etiological Factors: Social factors

Peer pressure . Modeling . Ease of availabilityReligious reasons . Poor social / familial support Rapid urbanization


PHYSIOLOGY 1/24/2017Dr Amit Gupta MD Psychiatry22

mouth and esophagus (in small amounts)stomach and large bowel (in modest amounts)proximal portion of the small intestine (the major site).AbsorptionRate of absorption is increased

Carbonated beverages

Absence of proteins, fats, or carbohydrates

Dilution of ethanol (20% by volume).

\

Neurotransmiters-Alcohol1/24/2017Dr Amit Gupta MD Psychiatry23IntoxicationWithdrawal

AAAlcohol PhysiologyCNS depressant : acting at several sites in BrainEnhances GABA activityStimulates serotonin receptor- pleasure & nausea.Stimulates dopamine & opioid receptors * euphoria & reinforcement.Provide energy ( empty calories) no nutritional value.Is a toxin to multiple organs.1/24/2017Dr Amit Gupta MD Psychiatry24

Behavioral Effects Effects of Blood Alcohol Levels in the Absence of ToleranceBlood Level, g/dLUsual Effect0.02Decreased inhibitions, a slight feeling of intoxication0.08Decrease in complex cognitive functions and motor performance0.20Obvious slurred speech, motor incoordination, irritability, and poor judgment0.30Light coma and depressed vital signs0.40Death


.


Complications :Central Nervous System:

Blackout(35%)Disturbed sleepImpaired judgment & coordination.Hangover syndromeHead injury & fractures

1/24/2017Dr Amit Gupta MD Psychiatry27With chronic useDelirium tremensSeizures (Rumfits )Alcoholic hallucinosisDelusional disorderAlcoholic dementiaSexual dysfunction

.Peripheral neuropathy(10%) Cerebellar degeneration or atrophy(1%)Wernicke's (ophthalmoparesis, ataxia, and encephalopathy) Korsakoff's (retrograde and anterograde amnesia) syndromes


1 in 500 alcoholicsComplications :Central Nervous System:

Complications of alcohol dependence:II. Social Complications:AccidentsMarital disharmonyDivorceOccupational problemsCriminalityFinancial difficulties


.Jessica Lal murder case Model and celebrity barmaid Jessica Lal was shot dead for refusing to serve alcohol to Union minister Venod Sharmas son Manu Sharma at Delhi, in April 1999.

1/24/2017Dr Amit Gupta MD Psychiatry302002 Hit & Run case. Salman khan was drunk and driving that night The Real Reason Why Women Were Molested In Bangalore On New Years Eve"Everyone was drunk and pushing each other, people behaved indecently. How Alcoholism Scars India By Kristen McGuiness 05/01/13 Amid alarming reports of soaring sexual assault rates,The Fixreports from India on the extent to which alcohol is to blame.

Alcohol abuse is associated with significantly higher rates of marital dispute & divorce 1/24/2017Dr Amit Gupta MD Psychiatry31

In India about 40% of work accidents have been attributed to alcohol use.The economic consequences of alcohol consumption can be severe, particularly for the poor. Apart from money spent on drinks, heavy drinkers may suffer other economic problems such as lower wages and lost employment opportunities & increased medical and legal expenses.

Complications - Acute Intoxicationblood alcohol levels between 100 and 200 mg/dlSymptoms of intoxication includes disinhibition of sexual or aggressive impulses, mood lability, impaired judgement, social or occupational functioning, slurred speech, incoordination, unsteady gait, nystagmus & flushed face. .


Complications - Alcohol withdrawalsigns and symptoms of AW typically appear between 6 and 48 hours after heavy alcohol consumption decreases. Initial symptoms may include headache, tremor, sweating, agitation, anxiety and nausea and vomiting, heightened sensitivity to light & sound, disorientation, insomniaThese initial symptoms of AW intensify and then diminish over 24 to 48 hours. Severe Alcohol Withdrawal syndrome characterized by one of the following 3 disturbances; delirium tremens, alcoholic seizures ,alcoholic hallucinosis.1/24/2017Dr Amit Gupta MD Psychiatry33

.1/24/2017Dr Amit Gupta MD Psychiatry34

Alcohol simultaneously enhances inhibitory tone (via modulation of GABA activity) and inhibits excitatory tone (via modulation of excitatory amino acid activity). Constant presence of ethanol preserves homeostasis. Abrupt cessation unmasks the adaptive responses to chronic ethanol use resulting in overactivity of the central nervous system.

The symptoms of AW reflect overactivity of the autonomic nervous system.

1. Delirium Tremens:most severe alcohol withdrawal syndrome. It occurs usually within 2 4 days of complete or significant abstinence from heavy alcohol drinking in 5% of patients.This is with the characteristic of Severe agitation,tremor, disorientation, visual hallucinations, tachycardia, hypertension, fever, sweating, insomnia, dehydration and electrolyte imbalance.Delirium tremens is a medical emergency with ~10% mortality if not treated


2. Alcoholic Seizures (rum fits):Generalized tonic clonic seizures occur in about 10% of alcohol dependence patients. Usually 12 48 hours after a heavy bout of drinking. Multiple seizures 2 6 at one time, are more common

1/24/2017Dr Amit Gupta MD Psychiatry363. Alcoholic hallucinosis:This is characterized by the presence of hallucinations during abstinence, following regular alcohol intake. These hallucinations persist after the withdrawal syndrome is over, and classically occur in clear consciousness

Pts usually come in complaining of withdrawal symptoms

1/24/2017Dr Amit Gupta MD Psychiatry37exclude other causes of presentation What is it that has brought you in to the clinic today? Any other substances of misuse ?

Depression/ Suicidality ? Reasons why drinking was exacerbated ? Age of starting drinking ? Last drink? How often they drink (try to take a day history) ? Try to quantify alcohol use to grams/SD symptoms of dependence? (withdrawal /tolerance)

CAGE questionnaire Taking an alcohol history

.

Social Situation ? Effects on daily living ? Occupation ? Relationships ? Diet adequate intake? / type of food (balanced?) / eating patternAlcohol related crime? Living situation? Previous attempts at abstinence:Have you ever tried to stop drinking before? Why?Why do you think unsuccessful?If not already revealed, assess desire to stop drinking

1/24/2017Dr Amit Gupta MD Psychiatry38General medical history / previous surgeryAlcohol-use specific -Liver disease / peptic ulcers /pancreatitis /ischaemic heart disease/ injuries?Drug history- Prescribed/ OTC / Recreational AllergiesFamily history -Focus on history of alcohol/drug dependence /mental illnessAssess risk to self / & risk to others:

can relieve patients discomfort and forestall cumulative effects that might worsen future withdrawals. 1/24/2017Dr Amit Gupta MD Psychiatry39Appropriate treatment of (AW)

Treating withdrawal1/24/2017Dr Amit Gupta MD Psychiatry40

CBC, LFTS, KFTS, Sr Amylase, glucose , Sr electrolytes Chest Xray, USG AbdomenBrain Imaging, ( MRI & EEG)

Out patient

Indoorsearch for evidence of liver /pancreatic disease , gastrointestinal bleeding, portal HT , cardiac arrhythmia, anemia , malnutrition & infection

History of severe withdrawal symptomsHistory of alcohol withdrawal seizures or delirium tremens Multiple past detoxifications Concomitant medical or psychiatric illness Recent high levels of alcohol consumption Lack of reliable support network Pregnancy1/24/2017Dr Amit Gupta MD Psychiatry41Relative Indications for Inpatient Alcohol Detoxification

1/24/2017Dr Amit Gupta MD Psychiatry42Liaison with other specialists as requiredGeneral principles of treating AW

1/24/2017Dr Amit Gupta MD Psychiatry43Recent clinical reviews have stressed the value of short-acting BZs, such as oxazepam (Serax) and lorazepam (Ativan) (Gallant 1989).More than 150 medications have been investigated for AW, clinicians disagree on the optimum medications & prescribing schedules.

.Treatment goal Adequate level of Sedation cardiac monitoring and oximetry and resuscitative equipment should be available1/24/2017Dr Amit Gupta MD Psychiatry44Examples of Medication Regimens DTDiazepam 5 mg IV (2.5 mg/min). repeat the dose in 5 to 10 minutesthird and fourth doses every 5 to 10 minutes20 mg for the fifth and subsequent dosesLorazepam 1 to 4 mg IV or IM every 5 to 15 minutes1 to 4 mg every 30 to 60 mins , until calm, then every hour as needed to maintain light somnolence 5 to 20 mg every hour as needed to maintain light somnolenceHaloperidol0.5 to 5mg IV or IM every 30 to 60 minutes as needed for severe agitation. .

..Adrenergic Medications. ( Propranolol) No evidence , however, that these medications block delirium or seizures. Most reviewers have concluded that adrenergic medications are of value largely as adjuncts to BZs in the management of AW. may be useful in outpatient settingsAntiseizure Medications. In Europe, carbamazepine and valproic acid and others) have been used successfully to treat AW Advantages- decrease seizures, non sedating, non habit forming, treat mood ,anxiety & agitationAntipsychotics such as haloperidol have been used to treat DTs. Lesser sedation and hypotension & provide behavioral control. Increase susceptibility to seizures, restlessness, agitation, and abnormal movements. Baclofen -GABA receptor agonist is able to suppress AWS Addolorato et al. (2003) also reported the ability of 75 mg/day baclofen (25 mg t.i.d.) to stop delirium tremens, the most severe complication of AWS.

Relapse preventionAversion therapy agents like disulfiram, Anti-craving agents: Acamprosate, Naltrexone, Baclofen , Topiramate, Fluoxetine etc.Behaviour therapy (The most commonly used therapy is aversion therapy)Psychotherapy , Group therapy

Psychosocial rehabilitation


Medications for Relapse prevention - 11/24/2017Dr Amit Gupta MD Psychiatry47Drug Dosage MOABenifitRemarksNALTREXONE50150 MG/D ORALLY, BLOCKING OPIOID RECEPTORS,

DECREASE ACTIVITY IN THE DOPAMINE-RICH VENTRAL TEGMENTAL REWARD SYSTEMSHORTEN SUBSEQUENT RELAPSESG ALLELE OF THE AII8G POLYMORPHISMContraindicated in liver disease, comorbid Opiate dependenceACAMPROSATE2 G/D DIVIDED INTO THREE ORAL DOSESINHIBITS NMDA RECEPTORSDECREASING MILD SYMPTOMS OF PROTRACTED Withdrawal. DISULFIRAM250 MG/D.PRODUCES VOMITING AND AUTONOMIC NERVOUS SYSTEM INSTABILITY IN THE PRESENCE OF ALCOHOL AS A RESULT OF RAPIDLY RISING BLOOD LEVELS OF THE FIRST METABOLITE OF ALCOHOL, ACETALDEHYDEAVERSION THERAPYCAN BE DANGEROUS WITH HEART DISEASE, STROKE, DIABETES MELLITUS, OR HYPERTENSION

Medications for Relapse prevention- 111/24/2017Dr Amit Gupta MD Psychiatry48Drug Dosage MOABenifitRemarksBaclofen1020 MG/three times /day ORALLY, GABA-b receptor agonistBlocks dopamine release in central reward areas (ventral straitum & prefrontal cortex)DECREASING SYMPTOMS OF WithdrawalDecrease cravingsCan be used in liver diseaseTopiramateescalating dose of 25 to 300 mg/daydual action facilitate GABAA-mediated inhibitory impulses, antagonize AMPA and kainate glutamate receptors, - suppress ethanol-induced nucleus accumbens dopamine (DA) release, thereby inhibiting the reinforcing effects of alcoholdecrease alcohol reinforcementreduced cravingadverse events are paresthesia (transient), anorexia, difficulty with memory/ concentration, and taste perversionOndansterone16mg /day5-HT3 antagonist that exerts its effects through cortico-mesolimbic dopamine system modulationDECREASING SYMPTOMS OF WIthdrawalMild adverse effects

Thank you 1/24/2017Dr Amit Gupta MD Psychiatry49

alcohol abuse

Health & Medicine