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Abuse vs. Dependence
Abuse: during 12 months, at least 1 of following:
Failure at social obligations due to drug use
Legal problems due to drug use
Use even in hazardous situations
Use despite having social problems
Dependence: during 12 months, at least 3 of the following:
Tolerance, increased amounts needed
Withdrawal
Need to use more
Cannot cut down or control use
Much time spent obtaining the drug
Social activities relinquished as direct result of drug use
Persistence of use despite being aware of harmful effects
Effects of Alcohol
CNS:
Acute: CNS depression, amnesia, fragmented sleep.
Chronic: Wernicke's and Korsakoff's syndromes (thiamine def), cerebellar deg, alcoholic dementia, peripheral neuropathy.
Cerebellar atrophy 2° to alcohol abuse tends to be more prominent in the anterior-superior vermis and paravermal zones, corresponding to the anterior lobe of the cerebellum.
Central truncal and gait ataxia is prominent feature, with lesser involvement of the upper limbs, and only rarely oculomotor symptoms of cerebellar dysarthria.
Thiamine deficiency causes the Wernicke-Korsakoff syndrome and is an important cause a peripheral neuropathy. Thiamine is mostly seen in chronic alcoholics. It is second only to traumatic lesions as the cause of pathological alterations in the brains of alcoholics.
Wernicke encephalopathy is characterized by fairly rapid onset of confusion, paralysis of extraocular muscles (particularly the lateral rectus), and ataxia. The syndrome may progress to coma and death if untreated but responds well to the administration of thiamine in the early stages. If not treated promptly, a permanent memory deficits known as Korsakoff psychosis the result. Korsakoff psychosis is characterized by an inability to either form new memories for retrieval ones, often accompanied by confabulation.
Thiamine deficiency has also been implicated in the development of atrophy of the superior vermis often seen in alcoholics, termed alcoholic cerebellar degeneration. In the peripheral nervous system, thiamine deficiency causes a peripheral axonal neuropathy.
Morphology: mamillary bodies of the hypothalamus, the dorsal medial areas of the thalamus, and the gray matter around the cerebral aqueduct, the last correlating with the eye movement abnormalities noted clinically. The earliest changes capillary endothelial proliferation associated with abnormal vascular permeability.
CVS:
Acute: negative inotropic, peripheral vasodilation.
Chronic: HTN, CM, increased HDL chol?
Pulmonary
Aspiration pneumonia is common
Increased susceptibility to gram-negative infections and tuberculosis
Recurrent bronchitis, asthma, chronic obstructive pulmonary disease
GI:
Acute: Esophageal and gastric inflammation, acute pancreatitis
Chronic: Mallory-Weiss tear, esophageal varices, portal HTN, chronic pancreatitis
Liver:
Acute: liver gluconeogenesis
Alcohol-induced hepatitis, cirrhosis
Fats accumulate in liver cells, leading to “fatty liver”
Risk of hepatocellular carcinoma 10 times higher than for general public.
Hematopoietic system:
Acute: macrocytosis
Chronic: thrombocytopenia, hypersplenism, decreased platelet aggregation
Splenic: alcohol use can lead to an enlarged spleen and sequestering of blood cells
Genitourinary system:
Acute: ED
Chronic: testicular atrophy, amenorrhea, ovarian atrophy, increased risk of abortion, fetal-alcohol synd.
Central nervous system and neurologic complications
“Blackouts”; fragmented sleep, with deep sleep deficiency
Wernicke’s and Korsakoff’s syndromes
Dementing illness: Marchiafava-Bignami disease, alcohol-induced persisting dementia, pellagrous encephalopathy (pellagra = dementia, diarrhea, dermatitis)
Cerebellar degeneration, peripheral neuropathy, decreased sensation of pain
Dermatologic: rosacea, spider angiomas, telangiectases, palmar erythema, seborrheic dermatitis
Endocrine
Intoxication can lead to hypoglycemia
Chronic alcohol use can lead to diabetes mellitus
In males: testicular atrophy, gynecomastia (from increase in estrogen production), decreased erectile capability, increased or decreased sex drive
In females: increased estrogen production, amenorrhea, decreased sex drive, infertility, spontaneous abortions, increase in male secondary sexual characteristics
Malnutrition
Poor absorption leading to multiple deficiencies: Vitamins A, C, D, and E, also niacin, pyridoxine, riboflavin, and thiamine
To prevent Wernicke’s encephalopathy, must administer thiamine before any intravenous administration of glucose-containing fluids
Hypomagnesemia and hypoalbuminemia common
Musculoskeletal
“Alcoholic myopathy” (painful, swollen muscles with increased creatinine phosphokinase level, also muscle weakness is common
Alterations of calcium metabolism can lead to increased risk of bone fractures, and especially osteonecrosis of femoral head
Oncologic: increased risk of cancers of head and neck (mouth, tongue, larynx), esophagus, stomach, liver, pancreas, breast.
Oral: periodontal disease, parotid gland enlargement.
Renal
Renal failure from hypertensive or diabetic effects on kidneys or from direct toxic effects of alcohol
Decreased uric acid excretion, which can lead to gout
Smoking:
ASK
ADVISE
ASSESS
ASSIST
ARRANGE
BAL: 43 mmol/L (0.2 g/dL) in nonhabituated patients is generally enough to cause impaired mental activity. >65 mmol/L (0.3 g/dL) is associated with stupor. Development of tolerance may allows the chronic alcoholic to remain awake at levels of >87 mmol/L (0.4 g/dL)
Alcohol intoxication: blood levels of 0.3 to 0.5% lead to respiratory depression, coma, death in non-dependent persons.
Testing:
Direct biomarker of alcohol testing: Preferred testing method. BAL. Urine Ethyl glucuronide, Ethyl sulfate in urine (last upto 5 days);
Phosphatidylethanol is a alcohol biomarker that is formed by the action of phospholipase D on ethanol. PEth160/181 and PEth 160/182. Half life 3-5 days. 2-4 weeks in window of detection. Serial monitoring of PEth may be useful to check for alcohol abstinence. Not affected by renal failure but advanced liver disease can have falsely elevated PEth concentrations. It should always be interpreted in the context of patient's clinical and behavioral history.
FFPET - Overview: Phosphatidylethanol (PEth), whole blood
<10 ng/mL: abstinent. Not detected
10-19 ng/mL: abstinent or light alcohol consumption (2 drinks/day for several days/week)
20-200 ng/mL: moderate alcohol consumption (4 drinks/day for several days/week)
>200 ng/mL: Heavy alcohol consumption or chronic alcohol consumption. (For men, consuming more than 4 drinks on any day or more than 15 drinks per week For women, consuming more than 3 drinks on any day or more than 8 drinks per week),
Indirect alcohol biomarkers look at the effect of alcohol on body chemistry: GGT, ALT, MCV
Approach: Order GGT, ALT, MCV, urine ethyl glucuronide, BAL, PEth.
Drinking in Moderation: According to the "Dietary Guidelines for Americans 2020-2025,” U.S. Department of Health and Human Services and U.S. Department of Agriculture, adults of legal drinking age can choose not to drink or to drink in moderation by limiting intake to 2 drinks or less in a day for men and 1 drink or less in a day for women, when alcohol is consumed. Drinking less is better for health than drinking more.
Binge Drinking:
NIAAA defines binge drinking as a pattern of drinking alcohol that brings blood alcohol concentration (BAC) to 0.08 percent - or 0.08 grams of alcohol per deciliter - or higher. For a typical adult, this pattern corresponds to consuming 5 or more drinks (male), or 4 or more drinks (female), in about 2 hours.
The Substance Abuse and Mental Health Services Administration (SAMHSA), which conducts the annual National Survey on Drug Use and Health (NSDUH), defines binge drinking as 5 or more alcoholic drinks for males or 4 or more alcoholic drinks for females on the same occasion (i.e., at the same time or within a couple of hours of each other) on at least 1 day in the past month.
Heavy Alcohol Use:
NIAAA defines heavy drinking as follows: For men, consuming more than 4 drinks on any day or more than 15 drinks per week For women, consuming more than 3 drinks on any day or more than 8 drinks per week
SAMHSA defines heavy alcohol use as binge drinking on 5 or more days in the past month.
If you can smell alcohol on the person’s breath, the likely level is greater than 0.125%
CAGE:
C—Have you ever felt you should cut down on your drinking?
A—Have people annoyed you by criticizing your drinking?
G—Have you ever felt bad or guilty about your drinking?
E—Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangoverr?
Two of four answered positively: 70%-80% indicative of alcohol dependence
Four of four answered positively: 100% indicative of alcohol dependence
HALT Questions:
Do you usually drink to get High?
Do you drink Alone?
Do you ever find yourself Looking forward to drinking?
Have you noticed that you are becoming Tolerant to alcohol?
BUMP Questions:
Have you ever had Blackouts?
Have you ever used alcohol in an Unplanned way (drank more than intended or continued to drink after having enough)?
Do you ever drink for Medicinal reasons (to control anxiety, depression, or the shakes?
Do you find yourself Protecting your supply of alcohol (hoarding, buying extra)?
Epidemiology
90% of U.S. population have had a drink
60% to 70% are current drinker
Lifetime prevalence of alcohol abuse: women, 5% to 10%; men, 10% to 20%
Lifetime prevalence of alcohol dependence: women, 3% to 5%; men, 13%
Up to 20% of primary care patients have their alcoholism go unnoticed
Life expectancy can be decreased by up to 10 years from use of alcohol
Alcohol is involved in more than 25% of those who die because of motor vehicle accidents (in some studies, up to 55%), drowning, suicide, homicide, or those who have suffered from abuse, assaults, or rape.
High rates of alcohol-use problems in whites more than in African Americans
Higher prevalence in Native Americans
Lesser prevalence in Asian Americans and Jews
Age at onset of alcohol abuse in about 17 years and for dependence, about 22 years
Metabolism
90% of alcohol is metabolized by oxidation in the liver, 10% is excreted unchanged in the urine, sweat, air (thus the Breathalyzer test is useful)
Alcohol dehydrogenase breaks down alcohol to acetaldehyde, then aldehyde dehydrogenase breaks down acetaldehyde to acetic acid.
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