Alcoholism and The Drug Alcohol

Alcoholism and The Drug "Alcohol"

Epidemiology of Alcohol Use

Addiction will not develop without initial exposure to the substance. There are many influences on the initiation of use:

Culture: actively encourages use at the earliest possible age via: peer pressure, advertising, and role models.

Family: Parental heavy use or abstinence (may be due to culture, Mormons, or bad experiences). Siblings who set an example by using, obtaining or sharing alcohol with younger siblings.

Location: Not only can determine availability of substance abused, but also becomes a conditioned stimulus.

Age of: 1^st drink is usually 12-15yo; if <10yo, this person is likely highly tolerant and from dysfunctional environment

1^st time drunk is typically midteens; 1^st EtOH related problems 18-25 yo; frequency and quantity ß by early 29-30yoa

Lifetime prevalence: 10% in adult males; this population is likely to get sick so is 20-35% in adult male medical/surgical patients

Family Risk: Increases with number of family members who are positive

DUI: Should create high level of suspicion because average drunk driver drives while intoxicated 150-450 X b/4 1^st arrest.

Blood Alcohol Level (BAL) at time of arrest is an indicator of tolerance (0.250 suggests tolerance)

Physiology of Intoxication

Mechanism: potentiates GABA’s action at receptor Cl^-channel and changes membrane fluidity.

Metabolism: Zero-order kinetics (independent of substrate concentration)-see MIND-125:EtOHÞ [ADH]Þ [ALDH]Þ Þ acetate.

metabolized at a rate of 120mg/kg/hr when hepatic function is normal therefore proportional to body weight
Typical 70 kg man metabolizes 8.5g/hr. 50Kg woman: 5-7g/hr

Tolerance: ß response to same amount. Mostly cerebellar adaptation; multitasking unaffected; ß in late stage.

Results from induction of P-450 reductase in hepatocytes. SER shunts metabolism to acetaldehyde.

Relation of EtOH consumed to BAL (blood alcohol level)

Measurement of pure alcohol: From least to most % EtOH: Beer, coolers, malt liquor, wine, Super Market liquor, liquor.

EtOH (g) in a beverage = % EtOH /100 X mL of beverage X 0.789. 12oz of 5% beer has 14.2g

Absorption: Slow in stomach (especially with food); More rapid in small intestines.

[EtOH]>30% Þ pyloric closure which ß absorption; [EtOH]=20-30% Þ most rapid; Carbonation Ý absorption rate

EtOH is distributed to the total body water (TBW): % Body H₂O in Men/Women: Lean 70:60 Obese 50:40

[EtOH(g) consumed] / [(person’s Wt in Kg) X (% Body H₂O) X .8(percent H₂O in blood) X1L/10dL] = BAL

Fall in BAL (g/dl/hr): Nondrinkers: .008-.016 Social drinkers: .010-.020 Most Alcoholics: .015-.040

intoxication can lead to death via alcohol poisoning or mishap.

BAL Concentration (g/dL)	Effect in Non-Tolerant	Effect in Tolerant Individuals
0.050 social drinker	ß inhibitions, judgement impaired	No obvious effects
0.075	loud, pressured speech	Little or No obvious effects
0.100 legally drunk at .080	Uninhibited	Lack of coordination
0.125	Uninhibited	Euphoria
0.150	Clearly intoxicated; cerebellar signs	Ibid. (same)
0.200-0.250	Lethargic	Labile
0.300-0.350	Stupor to coma	Sleepy, slow
>0.500	May be fatal	Coma
>0.588	FATAL	FATAL

Withdrawal

Types:

(1) Mild
(2) Seizures: can occur up to several days out (therapy includes not drinking)
(3) Hallucinosis: frightening to patient; patient is oriented and can tell they are not real
(4) DT’s (Delerium tremens): Delirium is present; these are medically high risk (therapy includes having someone stay with them round the clock.)

Treatment of Withdrawal Symptoms: Long-acting benzodiazepines (chloridiazepoxide-Librium)

Diagnosis of Alcoholism

Alcoholism affects five times as many men as women

Schuckits shorthand screening questions:

does the patient continue to use in spite of serious social or health problems?
ask about the problems that WAM A person: work, accidents, marital problems, arrests; are they EtOH related?

CAGE: Cut down; Annoyed; Guilt; Eye opener

T-AGE: Tolerance - Annoyed; Guilt; Eye opener modified for use with women.

when asking how much "Maximize": ask how many bottles not glasses.

Look at labs:

CBC: looking for anemia thrombocytosis
SMA: elevated uric acid levels
Note: if you can medically identify them , they are in trouble; women start to get sick 10 years earlier than men.

Clinical Course: is progressive with intermittent recovery; relapse quickly leads to problems; patients die 10 years younger.

Treatment of Alcoholism - The Doctor-Patient Relationship

With alcoholism, the Doctor-Patient relationship is centered on Denial and Anger by both parties.

(1) Doctors - physicians can develop attitudes that prevent them from recognizing a patient’s disease through:

Denial: blaming the patients for creating their own problem, believing that drinking is innocuous based on personal experience, or not wanting to have to recognize a drinking problem the physician is having.

Anger: being unable to understand why self-control is not possible, attributing behavior to lack of intelligence or unwillingness to cooperate or take medical advice.

(2) Patients - use of denial and anger defense mechanisms can be demonstrated by the following types of statements:

Denial - "It’s not a problem

Projection - "My wife would make anyone drink"

Minimization - "I really don’t drink that much" You do if it is more than 2 drinks on a regular schedule.

Rationalization - "Drinking is good for my heart"

Avoidance - "I am not here to discuss my drinking" Tell patient you are interested in the whole person.

Hostility - "Back off Doc!"

Treatment Plans: Detoxification; Disulfiram (Antabuse) works well with Physicians; Naltrexone (ReVia) has had small effect in relapse patients

12-step abstinence oriented programs: Outcome is a function of previous history, treatment and aftercare structure.

Early stages may be dealt with using controlled drinking.

SOAP: Just say no to alcohol because to use it is to wiLLT (ß ) yOUR SORPP.

LL: amounts consumed get Larger and periods of drinking last Longer

ß : attempts to decrease use

T: Tolerance is developed

OUR: more and more time is spent Obtaining, Using and Recovering from use.

SOR: reduced time spent in Social, Occupational or Recreational activities.

PP: use continues in spite of persistent or recurrent Physical or Psychological problems.