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ALCOHOL WHAT IS IT ?
It is a fuel and a non essential nutrient It is a cellular toxin
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Burden of Disease Attributable to Alcohol Among the 10 Leading Risk Factors for Disease In Developed Countries
Tobacco Blood pressure Alcohol Cholesterol Overweight Low fruit and vegetable intake Physical inactivity Illicit drugs Unsafe sex Iron deficiency
0% 2% 4% 6% 8% 10% 12% 14%
Ethanol
CH3CH2OH Uncharged, highly lipid soluble Hydroxyl group formation of H bonds Lipophilic group interact with non-polar domains of macromolecules Pharmacologically active agent in alcoholic beverages
Alcohol by Volume
ABV (alcohol by volume) = % shown on the container which gives an indication of strength Approximate ABVs: Beer/Lager 4% Cider 5% Vodka 40% (but can be up to 70%)
Wine 9 to 13%
Rum - 42.8%
A convenient way of measuring alcohol intake is in units of alcohol. One unit is equivalent to 8g of pure ethanol.
Metabolism of Ethanol
~90% rapidly metabolized in liver ~10% excreted unchanged in air and urine
Ethanol
Alcohol Dehydrogenase
Acetaldehyde
Aldehyde Dehydrogenase
Acetic Acid
NADH Shuttle
CH3COOH
NAD+ NADH
ATP
FXX.1 Harmful Use FXX.2 Dependance Syndrome FXX.3 Withdrawal State FXX.4 Withdrawal With Delerium FXX.5 Psychotic Disorder FXX.6 Amnestic Disorder FXX.7 Residual State FXX.8 Others FXX,9 Unspecified
DSM-IV Failure to fulfill role obligations Physically hazardous use Legal consequences Social/interpersonal problems
2.6x 4.1x
4.0x 7.1x
36.9x 6.4x
DSM-IV
(>=3 of the following)
1. Tolerance 2. Withdrawal 3. Repeated attempts to give up/reduce interspaces with heavy drinks 4. Large time spent on procuring 5. Primacy over other activities 6. Continued use despite knowledge/ Presence of harmful consequences
Alcohol dependence is a complex disorder Many pathways lead to the development of alcohol dependence Many genes are likely involved in the development of alcohol dependence
Pedigree studies of large, multigenerational families Studies of adoptees Studies of identical (MZ) and fraternal (DZ) twins
Genetics of Alcoholism
Alcohol Dependence
-- Four Times Risk -- Adoption and Twin Studies
No FH of alcoholism
Can abstain but binges Depressed/anxious Psychological dependence
FH of alcoholism
Impulsive a low 5HT function Antisocial Psychological dependence rare
40
Females Males
% alcoholic
30 20 10 0
FHN = no fam FHN= hxno FHP1 = 2 or 3 FHPZ = 1 only FHP2 = hx FHP1= only hx FHP3 = 1 + 2 FHP3 = hx or 3
fam hx of alcoholism
Source: Dawson et al., 1992
50 40 30 20 10 0
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Genotype-Environment Interaction
Moderate genetic loading High environ. sensitivity
13
Genetic Loading
Extent of Influence
Environmental (familial and non familial) Personality/Temperament (Endophenotype) Pharmacological effects of ethanol (Intermediate Phenotypes)
Neurobiology Brain Reward Mechanisms Primary brain reward relevant portion appears to be a subset of the mesolimbic projections originating in the ventral tegmental area and terminating in the nucleus accumbens. Neuroregulator Systems Role of serotonin in alcohol reinforcement.
Craving Irresistible urge to use a substance that compels drug seeking behaviour. Changes in endorphin, serotonin levels linked to craving for alcohol. Hippocampus is one of the anatomical sites suggested for craving Kindling has also been proposed as a mechanism of craving Membrane Studies Glycine, NMDA, AMPA and kainate receptors have emerged as possible sites for alcohol action
Behavioural conditioning factors External and internal cues TV advertisement, drug using friend Depressed or anxious mood, anger
Psychodynamic theories Individuals seek self-regulation outside of themselves through alcohol Defence Mechanisms Denial, Minimalization, Rationalization and Projection Socio-cultural and Family Dynamics Availability Cultural Patterns Legal Control Semi structured Interviews
CNS Effects Slowed performance and decreased thinking ability Increase in motor and cognitive problems Increased in coordination and errors in judgement, mood lability and deterioration in cognition Nystagmus, marked slurring of speech and blackouts Impaired Vital Signs and possible Death
BOWEL UPSET
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ULCERS
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VITAMIN DEFICIENCY
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VITAMIN DEFICIENCY
PELLAGRA
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CANCER OF LARYNX
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Alcohol withdrawal Autonomic hyperactivity Tremors Insomnia Nausea/vomiting Hallucinations Agitation Anxiety Seizures
Delirium Tremens
Alcohol withdrawal delirium Disorientation Impaired attention & concentration Psychomotor excitation Hallucinations vivid visual/auditory Fearfulness Delusions Other symptoms of withdrawal
Assessment
Barriers to assessment (related to pt) Denial of the problem Guilt about the substance use Feeling of shame Stigmatization of family and pt Dilemmas about physicians role and reaction Apprehension of possible legal consequences Barriers to assessment (related to clinician) Lack of correct scientific knowledge Judgemental attitude towards persons with substance abuse False opinion about therapeutic nihilism Fear of inability to manage substance use disorders
Remedies
Ensuring privacy and confidentiality Remaining non-judgemental Showing non-possessive warmth Expressing empathy and optimism Readiness to listen Avoiding ambiguous messages Being clear and firm regarding ones own role Introspective ability of the clinician
Purpose Setting Sources of Information Components of Assessment History Taking Examination Lab Investigation
History Taking
Chief complaints History of present illness Substance use pattern Onset, progression and recent use Complications of use Abstinence attempts Treatment history Past History Family History Personal History Early Childhood and development Adolescence Educational History Sexual History Marital History Occupational History
Premorbid Personality Physical Examination Vitals General Physical Exn Systemic Exn Signs of liver dysfunction Portal Hypertension Signs of neuro myopathy Signs of CNS dysfunction Signs of gastric dysfunction Mental State Examination
Biological Markers AST/ALT>2 highly suggestive GGT MCV Adenylate Cyclase CDT Erythrocyte Aldehyde Dehydrogenase Other Lab Parameters Screening Instruments and Rating scales
MAST, CAGE, AUDIT, CIWA-A
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