ALCOHOL – EFFECTS,

DEPENDENCE, WITHDRAWAL &

TREATMENTSt Vincent’s Hospital D&A

ServiceLisa Jayne Ferguson and Jeku

Jacob

Alcohol

CNS depressant: acting at several sites in brainEnhances GABA activityStimulates serotonin receptor = pleasure &

nauseaStimulates dopamine and opioid receptors

= euphoria & reinforcement

Provides kilojoules or energy but NO nutritional value

Is a toxin to multiple organs

Alcohol

1 standard drink (10 gm) raises the BAL by approximately 0.02

The body/liver processes 1 standard drink (10 gm) per hour

BAL continues to rise for 30 – 90 minutes after the last drink

The National Health & Medical Research Council 2009

Recommended maximum: (1/100 lifetime chance of death)

Women: 2 standard drinks/dayMen: 2 standard drinks/day (was 4)

Risky: ie increasing life time risk of deathWomen: 3 standard drinks/dayMen: 5 standard drinks/day

Known to cause harm: - chronic organ damageWomen: Over 4 standard drinks/dayMen: Over 6 standard drinks/dayPregnant women recommends 0 drinks – data still

sparseHealth benefits of Alcohol greatly exaggerated

Alcohol Dependence

More common than dependence on all other drugs combined in Australia

About 5% of Australians are dependent17 times as common as opioid dependence10% receive some form of treatmentOnly 1% are prescribed anti-craving

drugs ...this is compared to -30% opioid dependent people in treatment

Alcohol contributes to over 3,000 deaths per year and 50,000 hospitalisations

Alcohol Intoxication

0.01-0.02 Sense of well being

0.02-0.05 Slightly dizzy, talkative, over-confident, euphoria, clumsy

0.06-0.1 Decrease inhibitions & motor co-ordination. Increase pulse, ataxia, talkative

0.2-0.3 Poor judgement, nausea, vomiting

0.3-0.4 Blackout, memory loss, emotionally labile

0.4+ Stupor, breathing reflex threatened, deep anaesthesia, death (in non tolerant people)

High Alcohol Consumption – Long Term Effects GIT/Hepatic

Alcoholic Hepatitis Cirrhosis Pancreatitis Colitis

Nervous System Wernicke/Korsakoff’s Alcoholic Dementia Myopathy

Neuropathy Cardiac

AF Hypertension Cardiomyopathy

Endocrine Hypgoglycemia (don’t give

thiamine until you replace sugar) Hypogonadism

Oncology Increased risk of mouth, colon,

breast and larynx

Obstetric Foetal Alcohol Syndrom

Hematologic Bone marrow suppression leads

to macrocytic anemia Cirrhosis can lead to

thrombocytopenia

Alcohol Related Presentations to ED

Common Presentations Pt can usually come in complaining of withdrawal symptoms.

Hallucinations Tremors Sweats Anxiety Perceptual disturbances Seizures

Hemetemesis Abdominal Pain Falls Palpitations Productive Cough Jaundice Feeling unwell Intoxication Trauma/ Violence

History taking

Please take a good historyTry to quantify alcohol use to grams/SDHow often they drink (try to take a day history)Last drink? Age of starting drinkingReasons why drinking was exacerbated?Depression/SuicidalitySocial Situation Any other substances of misusePlease exclude other causes of presentation

Physical Findings

Signs of Chronic Liver DiseaseIn withdrawal

AnxiousSweatyTachycardic and HypertensiveTremulous

Wernicke’s: confused, ataxic and opthalmoplegicMalnourishedEncephalopathic if CLD

Investigations

UDSBACBSLFBC – may show macrocytic AnemiaUEC, LFTS, CMPB12 + folate – usually deficient INR - caogulopathyCT brain if history of fall/seizures or ataxic U/S abdomen if you suspect CLD

Management

HydrateThiamine (BEFORE GLUCOSE) – youll

never go wrong with giving more 300 mg tds iv please to start on all intoxicated

pts500 mg tds iv if you suspect wernicke’s

Glucose in thiamine deficiency precipitates wernicke’s

Replace Sugar please if glycopenicReplace Electrolytes

Alcohol Withdrawal

Is a syndrome of central nervous system hyperactivity

OnsetUsually between 6-24 hours after last regular

dose of alcohol (symptoms occur as blood alcohol concentration decreases)

DurationBetween 2-7 days (most commonly 4-5 days)Residual symptoms will last longer when

brain injury is involved

Withdrawal symptoms can range from mildly uncomfortable to life threatening

Symptoms can be prevented or alleviated

Early intervention can reduce or prevent progression to severe withdrawal, injury, dehydration or seizures

Rationale

Severe Alcohol Withdrawal Symptoms

CAN BE FATAL (RARELY)Seizures - 6-48 hoursMod-Severe Hypertension - 6-48

hours+ (Diastolic above 110)Disorientation - 48 hrs+Confusion - 48 hrs+Hallucinations - 48 hrs+Delirium Tremens- 48 hrs+

Alcohol Withdrawal ScalesThe most systematic & useful way to

measure the severity of withdrawal is to use a withdrawal scale

These provide a baseline against which changes in withdrawal severity may be measured over time

Research shows that the use of scales minimises both under-dosing & overdosing with benzodiazepines for alcohol withdrawal syndromes

AWS

Please do not start AWS prematurelyCalculate when BAC will return to normal, then start (Pt’s may go into withdrawal prior to this – clinical

perogative necessary)AWS not diagnostic...make diagnosis of withdrawal first

before instituting5 – 10 mg every 4 hours with a cap of 80 mg in the first

24 hoursCan get 120 mg in first 24 hours if appropriate

Perceptual disturbances/ Hallucinations in withdrawalCurtains/floor/furniture moving‘Insects over skin’ Hallucinations rarer and signify severity of

withdrawalcolour changesAnimal formsScary

These require antipsychoticsOlanzapine

Special Considerations

Use Oxazepam (7.5-45mg) if:Cirrhosis

Be careful with doses of BZDElderlyHead injury

Stay away from BZD if delerious, use antipsychotics instead

Difficulty in encepholapathy use lactulose!

Gorman House

Pts in ED who don’t require admission can be rehydrated, given thiamine and discharged

Gorman House is appropriate for detoxificationGorman House – 5/7 programPts need to be discharged on weaning diazepamDay 1 – 10mg qid Day 2 – 10 mg tdsDay 3 – 10 mg bdDay 4 – 10 mg daily

Wernicke-Korsakoff SyndromeForm of brain injury resulting from

thiamine deficiency If not treated early it can lead to

permanent brain damage & memory loss

Signs & symptoms of Wernicke’s encephalopathy (usually the first stage of the syndrome) =

1. Ophthalmoplegia (reduced eye movements) or Nystagmus (dancing eyes)

2. Ataxia 3. Confusion

Wernicke-Korsakoff SyndromeThis condition is reversible if recognised and

treated with parenteral vitamin B1 Parenteral thiamine should be

administered before any form of glucoseGlucose in the presence of thiamine

deficiency risks precipitating Wernicke’s encephalopathy

Korsakoff’s by itself : confabulation, amnesia and apathy

(ask: ‘do you remember me?’ Or ‘where did we meet before’

Wernicke-Korsakoff SyndromeNB: Studies have shown that the absorption

of PO thiamine in alcohol dependent patients is minimal to none!!!

Example of dosing regime: Thiamine 300mg tds IVI / IMI for 3/7’s , then

POIf WE established: Thiamine dose should be

increased

Potential Problems

High doses of Diazepam should not be used to treat alcohol related delirium

Diazepam can precipitate and cause delirium

Olanzapine/Haloperidol can lower seizure threshold

AWS should only be used for Alcohol, not opioid or benzodiazepine withdrawal

Treatment Options for PatientsFollow up with outpatient services / Tx – - 1:1 counselling (public & private), - Groups (SMART Recovery, AA’s) - Residential Rehab, - Pharmacotherapy‘s

* Impaired Cognition (Moderate-Severe)1.Cognistat /Neuropsych Assessment2.Guardianship /Inebriates Act3.Placement?????

Take Home Messages

Take a good alcohol historyDon’t start the AWS too earlyPlease replace thiamine iv before glucose

(at least one dose) AWS not diagnostic – pt not improving,

consider alternative diagnosis

THANK YOU SVH A&D Service