Oleh: Dr Izani Uzair bin Zubair Ketua Penolong Pengarah(Perubatan) Jabatan Kesihatan Negeri Pulau Pinang

Ethyl alcohol or ethanol

Fermentation process
Yeast organisms break down sugar

Distillation
Alcohol vapors are released from the mash at high

temperatures

Proof
Measure of the percent alcohol

80 proof whiskey = 40% alcohol

Wine and beer

Absorbed more slowly than distilled beverages

Carbonated alcoholic beverages (champagne and sparkling wines)

Absorbed more quickly than non-carbonated

Carbonated beverages (soda and seltzer) and drinks with mixers

Relax the pyloric valve and empty stomach contents into

intestines
Increases rate of alcohol absorption

The more alcohol you consume, the longer absorption takes

Alcohol and injuries

13% of ER visits by undergrads are for alcohol-

related injuries
Patients with a BAC >0.08 are 3.2 times more likely

to have a violent injury than an unintentional injury

Most people admitted to ER are men 21 and over,

most as a result of accidents or fights in which alcohol was a factor

Alcohol poisoning Consuming large amounts of alcohol in short period of time can be lethal Alcohol alone or mixed with another drug responsible for more deaths due to toxic overdose than any other substance Death caused by either central nervous system and respiratory depression or by inhalation of vomit or fluid into the lungs Signs include inibility to be roused, weak and rapid pulse, unusual breathing pattern, and cool, damp, pale or bluish skin If wait to call for help until person is unconscious, risk of death increases tenfold

Decision making skills impaired

Alcohol lowers inhibitions, impairing ability to make

wise decisions regarding sexual activity

70% of college students admit to having engaged in

sexual activity primarily as a result of being under influence of alcohol

Less likely to use safer sex practices

Risk of contracting STI or unplanned pregnancy increases among those who drink heavily

Alcohol affects men and women differently

Women have less body fat

Women have half as much alcohol dehydrogenase

enzyme that breaks down alcohol in the stomach

More vulnerable to impairment due to alcohol consumption

Hormonal differences and use of oral contraceptives

likely to contribute to longer periods of initoxication

Immediate effects of alcohol

Reduces frequency of nerve transmissions Dehydration Water is lost from cerebrospinal fluid Alcohol irritates the gastrointestinal system Hangovers Congeners forms of alcohol metabolized more slowly Be informed of drug and alcohol interactions

What are some symptoms experienced by someone with a hangover?

Long-term effects of alcohol

Effects on the Nervous System Cardiovascular Effects Liver disease

Cirrhosis

Alcoholic hepatitis
Cancer Chronic inflammation of pancreas

Impairs ability to recognize and fight bacteria and viruses

 Labs (BAL, CBC, Chem 22, Mg, TSH, RPR,

lipase, UDS, UA, pregnancy test) PPD CXR EKG Acetaminophen and salicilate level as indicated

 Sites include stomach, small intestine, and colon Dependent on gastric emptying time Metabolized primarily in the liver by oxidation Alcohol dehydrogenase exhibits zero-order kinetics

(15 mg/dl/hr) Proportional to body weight Microsomal ethanol oxidizing system (MEOS) Alcohol inhibits cytochrome P-450

Alcohol

ADH
Acetaldehyde

ALDH
Acetic acid and water

 20-99mg% loss of muscular coordination, change in behavior 100-199mg% ataxia, mental impairment 200-299mg% obvious intoxication, nausea and vomiting 300-399mg% severe dysarthria and amnesia

 400-600mg% coma occurs 600-800mg% decreased respirations and blood pressure,

obtundation, often fatal Important to remember the role of tolerance in all these categories

 Cardiovascular and respiratory support to control blood

pressure and maintain airway Intravenous fluids (Banana Bag-NS, thiamine, MVI, Folate, B-12) Assess for other drug use especially benzos or opioids as antagonists can be used Closely monitor until withdrawal begins and then start treatment

MSSA (Modified Selective Severity Assessment) CIWA-A (Clinical Institute Withdrawal Assessment for Alcohol) Advantage for personnel to monitor progress and treat accordingly Disadvantage is cookbook approach

Most people abstain or drink moderately placing them at low risk for alcohol use disorders. In general, Moderate Drinking is up to 2 drinks/day for men; up to 1 drink/day for women

ONE DRINK-12 OUNCE CAN OR BOTTLE OF BEER OR WINE COOLER/ONE 5 OUNCE GLASS OF WINE

Nearly 3 in 10 U.S. adults engage in these high-risk drinking patterns1

Men: more than 14 drinks in a typical week more than 4 drinks on any day more than 7 drinks in a typical week more than 3 drinks on any day

Women:

A binge is a pattern of drinking alcohol that brings blood alcohol concentration (BAC) to 0.08 gm% or above. For the typical adult, this pattern corresponds to consuming 5 or more drinks (male) or 4 or more drinks (female) in about 2 hours. Binge drinking is clearly dangerous for the drinker and for society

GENES : 60% addictive,both alcohol specificand non specific Enviroment : 40% both shared and non shared

1 unit = 10ml of pure ethanol

Beer (4% ABV) 1 pint 2 units

Wine (12% ABV) 175ml glass 2 units 750ml bottle 9 units

Whiskey (40% ABV) 25ml measure 1 unit

Units per week

Drinker type
Men Moderate Less than 21 Women Less than 14

Hazardous
Harmful

21 50
50+

14 35
35+

Disorder Odds

Anxiety Disorder Mood Disorders (especially Major Depression) Personality Disorders Antisocial Personality Disorder Drug Dependence Nicotine Dependence

2.6x

4.1x 4.0x 7.1x 36.9x 6.4x

Alcohol use, abuse, and dependence are complex behavioral traits influenced by many factors:
genetic and biological responses
environmental influences

stages of development, from childhood to early

adulthood

 Lots of alcoholism treatments use a combination

of psychological means (such as CBT) in combination with aversion therapy aided by drugs. Most drugs used in treating alcoholism are aimed at creating adverse reaction to imbibing alcohol. Currently on the market, there are a limited number of drugs to treat alcoholism.

 Under normal conditions,

alcohol is broken down by alcohol dehydrogenase into acetaldehyde, which is further broken down into acetic acid by acetaldehyde dehydrogenase. Antabuse works by blocking acetaldehyde dehydrogenase, causing an excess build up of acetaldehyde.

 Due to the excess build up of acetaldehyde in the

bloodstream, patients may feel nausea, vomit, have headaches, chest pain, and several other symptoms after only five to ten minutes after drinking. There appears to be no tolerance to Antabuse; extended use of the drug only adds to its effect as it is both absorbed and excreted slowly by the body.

 Due to its slow excretion from the body,

Antabuse can be effective 5-7 days from the last dose. Therefore, patients using Antabuse to treat alcoholism must continually take the drug (this drug can be court mandated). Antabuse also shows some effects as a dopamine breakdown inhibitor, and therefore is also being investigated as a treatment for cocaine addiction.

 Due to its interaction with the enzyme dopamine-betahydroxylase , which breaks down doapmine, Antabuse adverse affects when combined with drugs affecting the release and re-uptake of dopamine (Such as Ritalin, Adderall, and Cocaine). Metabolism of other drugs may be inhibited by Antabuse (such as Benzodiazepines, morphine, and barbituates). Extremely important to take under consideration when someone is undergoing other medical treatment along with the treatment for alcohol addiction.

 Naltrexone is
metabolized in the liver into a variety of metabolites, with the 6-naltrexol being the metabolite useful in treating alcoholism. The mechanism of action is not quite fully understood. Approved for use in the treatment of alcoholism in April of 2006.

 After metabolizing into the 6--naltrexol, the metabolite is

believed to act as a competetive antagonist at opiod receptors. It is because of this reaction that Naltrexone is believed to interact with the dopaminergic mesolimbic pathway, which alcohol activates, therby causing pleasurable feelings.

 Naltrexone is aimed at reducing the

psychological need or craving for alcohol. Naltrexone can be administered in a 50mg tablet with some nauseating side effects. A Naltrexone shot, administerd intrmuscularly, is also available. Naltrexone has been shown to be effective for up to 30 days.

 Naltrexone is considered a relatively safe drug

for the treatment of Alcoholism. Little drug-drug interactions have been shown and do not seem significant, except for Naltrexones interaction with opiod analgetics. Some patients, while on Naltrexone have been shown to turn away from alcohol only to pick up another drug. After treatment with naltrexone, opiod receptors are very sensitive and can lead patients to overdose on some other drug.

 First approved by the

FDA in 2004, although it has been approved in Europe since 1989 Part of the reason for the delay of approval in the US was due to the action of Acamprosate not being fully understood

 Alcohol inhibits the activity of receptors known as NMethy-D-aspartate receptors (or NMDARs), causing the brain to create more NMDARs Absence of alcohol, or no inhibition of the receptor, causes these receptors to be overly active and cause symptoms such as delirium tremens (DT). Acamprosate is thought to reduce glutamate surges that excite NMDARs. This property makes Acamprosate useful in treating the withdrawal symptoms in alcoholics. Acamprosate has also been shown in some studies to act as a neuro-protectant and protect neurons from damage caused by alcohol withdrawal

 Benzodiazepines have also been used to

treat alcohol withdrawal due to their interaction with the GABA receptor. Emetine can be used in combination with other drugs (creating a literal drug cocktail) and be used in aversion therapy as the cocktail will induce nausea and vomiting.

 Because of the complexity of alcoholism, drugs

alone are not effective in curing alcoholism. Cases must also be treated on a case by case basis, there is no set proven effective method for everyone. Psychological measures (CBT) in combination with drugs are usually employed, although sometimes addictions are treated without drug use.

Cognitive behavioral therapy tries to understand how an individual's learning has occurred. A therapist using CBT will, firstly, attempt to help you understand the reasons for your 'bad' behavior and why you developed such a negative response to certain 'triggers'. more important goal of CBT, is to identify and learn better responses, or coping strategies, for the triggers.

You, for example, may suffer from stress. In order to unwind after a bad day you have a drink which relaxes you. You learn that alcohol relieves stress. Over time you become dependent on this drink to relax, before long you are having two, three, a bottle. Your wife complains you are drinking too much, the relationship suffers. Hangovers become common and you get into trouble at work ultimately being made redundant. This causes more friction with your wife and so on.

A therapist , using your testimony, will help you identify the reasons for your drinking; you learned that alcohol relieved stress, and every time you drank to ease the stress, the idea that drink relieved stress was reinforced. However, over time drink no longer fulfilled this function, in fact it created more stress. Despite this you continued with the behavior becuase of the'maladaptive learning process'.

Having identified the reason for the behavior you and the therapist would then identify coping skills that could be utilized to deal with stress in the future. Skills that didn't involve drinking.