Symposium - Alcohol Misuse

Question 1

Through what mechanisms does alcohol contribute to mortality in the following age groups:

• 16 to 34
• 34 to 64
• 64+

Answer 1

• 16-34 years
  
  • Accidents/traumas
  • Self-harm and suicide
  • Alcohol intoxication (poisoning)
• 34-64 years
  
  • Alcohol related liver disease
• 64+
  
  • Alcohol related cancers

Question 2

What are the principles of the WHO global alcohol strategy?

Answer 2

• Availability
• Regulation of marketing
• Price controls (cheapest alcohol)
• Leadership and mentoring
• Early identification and advice

Question 3

What are the effects of alcohol at low and high doses?

Answer 3

• Low doses
  
  • Euphoria, reduced anxiety, relaxation, sociability
• High doses
  
  • Intoxication (the pathological state produced by a drug, serum, alcohol or any toxic substance), basically poisoning
  • Impaired attention and judgement, unsteadiness, flushing, nystagmus, mood instability, disinhibition, slurring, stupor, unconsciousness

Question 4

What is intoxication?

Answer 4

• Intoxication (the pathological state produced by a drug, serum, alcohol or any toxic substance), basically poisoning

Question 5

What is used to grade alcoholism?

Answer 5

ICU-10

Question 6

What are the different grades of alcoholism?

Answer 6

• Harmful use
  
  • Pattern of use causing damage to physical or mental health
  • Use > 1 month or repeatedly over 12 months
• Dependence
  
  • 3 or more of the following for >1month or repeatedly over 12 months
    
    • Cravings/compulsions to take
    • Difficulty controlling use
    • Primacy
    • Increased tolerance
    • Physiological withdrawal on reduction/cessation
    • Persistence despite harmful consequences
• Withdrawal state
  
  • Group of symptoms of variable clustering and severity on complete/relative withdrawal of a psychoactive substance, after persistent use of that substance
  • Tremor, weakness, nausea, vomiting, anxiety, seizures, confusion, agitation, death
  • Delirium tremens
    
    • Profound confusion, tremor, agitation, hallucinations, delusions, sleeplessness, autonomic over-activity
    • Death – cardiovascular collapse, infection, hyperthermia, seizures of self-injury
    • Usually 48-72 hours after alcohol stopped

Question 7

What is the criteria for the following grades:

• harmful use
• dependence
• withdrawal state

Answer 7

• Harmful use
  
  • Pattern of use causing damage to physical or mental health
  • Use > 1 month or repeatedly over 12 months
• Dependence
  
  • 3 or more of the following for >1month or repeatedly over 12 months
    
    • Cravings/compulsions to take
    • Difficulty controlling use
    • Primacy
    • Increased tolerance
    • Physiological withdrawal on reduction/cessation
    • Persistence despite harmful consequences
• Withdrawal state
  
  • Group of symptoms of variable clustering and severity on complete/relative withdrawal of a psychoactive substance, after persistent use of that substance
  • Tremor, weakness, nausea, vomiting, anxiety, seizures, confusion, agitation, death
  • Delirium tremens
    
    • Profound confusion, tremor, agitation, hallucinations, delusions, sleeplessness, autonomic over-activity
    • Death – cardiovascular collapse, infection, hyperthermia, seizures of self-injury
    • Usually 48-72 hours after alcohol stopped

Question 8

What is seen in delirium tremens?

Answer 8

• Profound confusion, tremor, agitation, hallucinations, delusions, sleeplessness, autonomic over-activity
• Death – cardiovascular collapse, infection, hyperthermia, seizures of self-injury
• Usually 48-72 hours after alcohol stopped

Question 9

When does delirium tremens usually begin?

Answer 9

• Usually 48-72 hours after alcohol stopped

Question 10

What are some examples of problems that alcohol can cause?

Answer 10

• Physical health
  
  • Affects every part of your body, every organ system
  • Find examples below
• Mental health
  
  • Depression
  • Sleep disruption
  • Morbid jealousy
  • Alcohol hallucinosis
  • Deliberate self-injury
  • Suicidal thoughts/acts
• Relationships
  
  • Aggression
  • Marital difficulties
  • Poor parenting
  • Loss of friendships and social supports
• Employment, financial
• Legal

Question 11

What are some health conditions directly related to alcohol?

Answer 11

• Wernicke’s encephalopathy
  
  • Confusion, ataxia, opthalmoplegia, nystagmus
• Koraskoff’s psychosis
  
  • Prominent impairment of recent and remote memory, preservation of immediate recall, impaired learning and disorientation
  • May exhibit nystagmus and ataxia
  • Due to thiamine deficiency

Question 12

Wernicke’s encephalopathy - clinical featrures

Answer 12

• Confusion, ataxia, opthalmoplegia, nystagmus

Question 13

Koraskoff’s psychosis - clinical features

Answer 13

• Prominent impairment of recent and remote memory, preservation of immediate recall, impaired learning and disorientation
• May exhibit nystagmus and ataxia

Question 14

Karoskoff’s psychosis - aetiology

Answer 14

• Due to thiamine deficiency

Question 15

What are some screening tools for alcoholism?

Answer 15

• CAGE (2 or more indicates alcohol problem)
  
  • Have you tried to Cut down
  • Have you felt Annoyed by people critisising your drinking
  • Have you felt Guilty about drinking
  • Have you felt the need to have an Eye opener
• AUDIT (alcohol use disorders identification test)
• FAST (4 questions)
• PAT (Paddington Alcohol Test) – used in A and E

Question 16

What are the 4 questions of CAGE?

Answer 16

• CAGE (2 or more indicates alcohol problem)
  
  • Have you tried to Cut down
  • Have you felt Annoyed by people critisising your drinking
  • Have you felt Guilty about drinking
  • Have you felt the need to have an Eye opener

Question 17

What screening tool is used in A&E?

Answer 17

• PAT (Paddington Alcohol Test) – used in A and E

Question 18

Describe the management of alcoholism?

Answer 18

• Practical advice, education, harm reduction
• Holistic/bio-psycho-social approach
  
  • Support for patient and family
  • Psychological help such as CBT, group therapy
  • Social work input (benefits, housing, child protection)
  • Skills training
  • Community support such as AA
  • Inpatient or residential treatment
  • Medication
    
    • Thiamine to prevent Wernicke-Korsakoff syndrome
    • Management of alcohol withdrawal – benzodiazepines
    • Aversion/deterrent medication – disulfiram
    • Anti-craving medication – acamprosate, naltrexone, nalmefene

Question 19

What medications can be used in alcoholism?

Answer 19

• Thiamine to prevent Wernicke-Korsakoff syndrome
• Management of alcohol withdrawal – benzodiazepines
• Aversion/deterrent medication – disulfiram
• Anti-craving medication – acamprosate, naltrexone, nalmefene

Question 20

What organ systems are affected by alcohol?

Answer 20

Each organ system is affected, particular the liver

Question 21

Alcoholic fatty liver - prognosis

Answer 21

• 20% progress to cirrhosis
• Alcohol abstinence returns fatty liver to normal

Question 22

Alcohlic fatty liver - epidemiology

Answer 22

• Most heavy drinkers have fatty liver

Question 23

Acute alcoholic hepatitis - diagnosis critera

Answer 23

• Alcohol intake >6u(units) per day
• Jaundice with bilirubin > 80mg/dl
• No other aetiology for liver inflammation

Question 24

Alcoholic hepatitis - prognosis

Answer 24

• Very high mortality, no specific treatment yet

Question 25

What scoring system is used to grade acute alcoholic hepatitis?

Answer 25

GAHS score

Question 26

What does the GAHS score consider?

Answer 26

Question 27

Mortality is high for what GAHS score?

Answer 27

If score is 9 or more mortality is high, but steroids help

Question 28

How can alcoholism cause malnutrition?

Answer 28

* 60% of chronic abusers have malnutrition * Most of the calories is from alcohol * Total energy intake reduced * Nausea and vomiting * Abdominal pain * Diarrhoea

Question 29

How do different peopole with alcoholic cirrhosis die?

Answer 29

Mortality in alcoholic cirrhosis is high: * 75% die of liver compensation * 25% die from hepatocellular cancer sequelae * Most need transplant * ARLD most common indication for transplant

Question 30

What is commonly seen in teenangers who drink a lot?

Answer 30

Alcohol and teenagers: * Cirrhosis rare * Deranged LFT common, especially in obese

Question 31

Describe the pathophysiology of alcoholic ketoacidosis?

Answer 31

* Lipolysis tends to increase because of increased levels of cortisol and catecholamines, causes by extra stress placed on body by alcohol * Lipolysis contributes to abundance of FFA, which in turn sees diverted ketone production * Usually the ketone beta-hydroxybutyrate * Excess alcohol metabolised drives NADH+ production, which drives production of ketone beta-hydroxybutyrate * Chronic alcohol misusers have depleted reserve, ethanol will provide calorie intake though glycogen stores depleted * Metabolism of ethanol raises NADH/NAD which impairs hepatic gluconeogenesis and the metabolism of lactate * So patient has impaired ability to make glucose, or metabolise lactate driving the hypoglycaemia and acidosis

Question 32

What ketone is usually seen in alcoholic ketoacidosis?

Answer 32

* Usually the ketone beta-hydroxybutyrate

Question 33

What is done to stailise a patient with alcoholic ketoacidosis?

Answer 33

To stabilise patient: * IV fluids * IV vitamin B1 (thiamine)

Question 34

What is vitamin B1?

Answer 34

Thiamine

Question 35

Why is thiamine so important for metabolism?

Answer 35

Thiamine is used at multiple points as co-factor

Question 36

What act describes the alcohol laws?

Answer 36

Licensing (Scotland) Act 2005

Question 37

What are some of the principles of the Licensing (Scotland) Act 2005?

Answer 37

* Provides regulation of the sale of alcohol * Illegal to * Sale to under 18 or to allow consumption of * Attempt to enter pub whilst drunk * Sell to drunk person * Whilst drunk behave in disorderly manner * Refuse to leave * Allow drunkenness or disorderly conduct

Question 38

In relation to the law, what does alcohol increase the risk of?

Answer 38

* Committing crime * Becoming victim of crime or misadventure * Adverse incidents