medicnotes.org.uk :: Alcohol abuse

Alcohol abuse

Alcohol dependence syndrome:

There are essential elements to this syndrome:

A compulsive need to drink
Is a stereotyped pattern of drinking
Drinking takes priority over all other activities
Tolerance to alcohol is altered (however, in the later stages of dependence, tolerance falls)
Repeated withdrawal symptoms occur some 8-12 hours after cessation of drinking (thus, symptoms characteristically appear on waking)
There may be relief drinking (i.e. drinking to overcome a hangover)
Severely dependent drinkers who drink again after a period of abstinence are likely to relapse quickly and return to their old addictive pattern

Extent of the problem:

At least 300,000 people in the UK have a drink-related problem (estimated at 5% of men and 2% of women)

20% of male admissions to acute medical wards are due to alcohol-related problems

About 35% of attendees at A&E have a blood-alcohol level > legal limit for driving

Clues in the history to help you detect an alcoholic:

Absenteeism from work
Frequent attendances for unexplained dyspepsia or GI bleeds
Hospital admissions for accidents of all kinds
Fits, ‘turns’ or falls

Signs to help you detect an alcoholic:

Bloodshot conjunctivae
Smell of stale alcohol
Facial appearance resembling Cushing’s syndrome
Marked tremor
Signs of alcohol-related diseases

‘At risk’ factors:

Marital difficulties may conceal heavy drinking or may be used to justify it
Alcohol abusers have 2x as many days off work as their more sober colleagues
There may be an affected relative (25% of the male relatives of alcohol abusers have similar problems)
High-risk occupations include:

Company directors
Salesmen
Doctors
Journalists
Publicans
seamen

There may be associated physical and mental conditions (e.g. depression)

Common alcohol-related psychological and social problems:

Psychological Social

Depression Marital and sexual difficulties

Anxiety and phobias Family problems

Memory disturbances Child abuse

Delirium tremens Employment problems

Attempted suicide Financial difficulties

Pathological jealousy Delinquency and crime

Homelessness

Laboratory markers of alcohol abuse:

Elevated γ-Glutamyl-Transpeptidase (γ-GT)
Elevated mean corpuscular volume (MCV)
Blood/urinary alcohol levels

Symptoms of alcohol dependence:

Unable to keep a drink limit
Difficulty in avoiding getting drunk
Spending a considerable time drinking
Missing meals
Memory lapses
Restless without drink
Organizing day around drink
Trembling after drinking the day before
Morning retching and vomiting
Hallucinations, frank delirium tremens

Delirium tremens:

This is the most serious withdrawal state and occurs 1-5 days after alcohol (or barbiturate) withdrawal
Patients experience:

Disorientation
Agitation
Marked tremor
Visual hallucinations (e.g. pink elephants)

Signs include:

Sweating
Tachycardia
Tachypnoea
Pyrexia
Dehydration
Wernicke-Korsakoff syndrome

If delirium tremens is not treated promptly, death can occur

Management of delirium tremens:

The patient should be hospitalized

Diazepam 4-100mg for 2 days, then reduced
Any dehydration/electrolyte imbalance should be corrected
Any systemic infection should be treated
B vitamins should be given parenterally

Psychological treatment of alcohol dependence:

Provision of information concerning safe drinking levels
Recommendations to cut down where indicated
Simple support and advice concerning associated problems

With addictive drinking, the most favoured psychological treatment is group therapy which involves identification, confession, emotional arousal, the implantation of new ideas and the long-term support by fellow members of the group

Drug treatment of alcohol dependence:

Long-term treatment with drugs should NOT be prescribed in those patients who continue to abuse alcohol

Disulfiram (Antabuse):

Reacts with alcohol to cause very unpleasant acetaldehyde intoxication and histamine release
A daily maintenance dose means that an alcohol-dependent drinker must wait until the disulfiram is eliminated from the body before drinking safely
This drug, therefore, provides a ‘chemical fence’ around the patient for at least 24 hours
Disulfiram implants have been developed that have a treatment life of about 6 months

Outcome:

Whereas in the case of non-dependent heavy drinkers the goal of normal drinking within safe limits can be a very reasonable one, the alcohol-dependent drinker must be persuaded to abstain.

Research suggests that up to 40-50% of alcohol-dependent drinkers are abstinent or drinking very much less up to 2 years following intervention


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	Alcohol abuse Alcohol dependence syndrome: There are essential elements to this syndrome: A compulsive need to drink Is a stereotyped pattern of drinking Drinking takes priority over all other activities Tolerance to alcohol is altered (however, in the later stages of dependence, tolerance falls) Repeated withdrawal symptoms occur some 8-12 hours after cessation of drinking (thus, symptoms characteristically appear on waking) There may be relief drinking (i.e. drinking to overcome a hangover) Severely dependent drinkers who drink again after a period of abstinence are likely to relapse quickly and return to their old addictive pattern Extent of the problem: At least 300,000 people in the UK have a drink-related problem (estimated at 5% of men and 2% of women) 20% of male admissions to acute medical wards are due to alcohol-related problems About 35% of attendees at A&E have a blood-alcohol level > legal limit for driving Clues in the history to help you detect an alcoholic: Absenteeism from work Frequent attendances for unexplained dyspepsia or GI bleeds Hospital admissions for accidents of all kinds Fits, ‘turns’ or falls Signs to help you detect an alcoholic: Bloodshot conjunctivae Smell of stale alcohol Facial appearance resembling Cushing’s syndrome Marked tremor Signs of alcohol-related diseases ‘At risk’ factors: Marital difficulties may conceal heavy drinking or may be used to justify it Alcohol abusers have 2x as many days off work as their more sober colleagues There may be an affected relative (25% of the male relatives of alcohol abusers have similar problems) High-risk occupations include: Company directors Salesmen Doctors Journalists Publicans seamen There may be associated physical and mental conditions (e.g. depression) Common alcohol-related psychological and social problems: Psychological Social Depression Marital and sexual difficulties Anxiety and phobias Family problems Memory disturbances Child abuse Delirium tremens Employment problems Attempted suicide Financial difficulties Pathological jealousy Delinquency and crime Homelessness Laboratory markers of alcohol abuse: Elevated γ-Glutamyl-Transpeptidase (γ-GT) Elevated mean corpuscular volume (MCV) Blood/urinary alcohol levels Symptoms of alcohol dependence: Unable to keep a drink limit Difficulty in avoiding getting drunk Spending a considerable time drinking Missing meals Memory lapses Restless without drink Organizing day around drink Trembling after drinking the day before Morning retching and vomiting Hallucinations, frank delirium tremens Delirium tremens: This is the most serious withdrawal state and occurs 1-5 days after alcohol (or barbiturate) withdrawal Patients experience: Disorientation Agitation Marked tremor Visual hallucinations (e.g. pink elephants) Signs include: Sweating Tachycardia Tachypnoea Pyrexia Dehydration Wernicke-Korsakoff syndrome If delirium tremens is not treated promptly, death can occur Management of delirium tremens: The patient should be hospitalized Diazepam 4-100mg for 2 days, then reduced Any dehydration/electrolyte imbalance should be corrected Any systemic infection should be treated B vitamins should be given parenterally Psychological treatment of alcohol dependence: Provision of information concerning safe drinking levels Recommendations to cut down where indicated Simple support and advice concerning associated problems With addictive drinking, the most favoured psychological treatment is group therapy which involves identification, confession, emotional arousal, the implantation of new ideas and the long-term support by fellow members of the group Drug treatment of alcohol dependence: Long-term treatment with drugs should NOT be prescribed in those patients who continue to abuse alcohol Disulfiram (Antabuse): Reacts with alcohol to cause very unpleasant acetaldehyde intoxication and histamine release A daily maintenance dose means that an alcohol-dependent drinker must wait until the disulfiram is eliminated from the body before drinking safely This drug, therefore, provides a ‘chemical fence’ around the patient for at least 24 hours Disulfiram implants have been developed that have a treatment life of about 6 months Outcome: Whereas in the case of non-dependent heavy drinkers the goal of normal drinking within safe limits can be a very reasonable one, the alcohol-dependent drinker must be persuaded to abstain. Research suggests that up to 40-50% of alcohol-dependent drinkers are abstinent or drinking very much less up to 2 years following intervention
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