Important definitions• Abuse: Use of any drug, usually by self-administration, in a

manner that is not approved by social or medical patterns.

• Misuse: Similar to abuse, but usually applies to drugs prescribedby physicians that are not used properly.

• Dependence: repeated use of a drug or chemical substance,withor without physical dependence.

Tolerance: phenomenon in which, after repeated use, a drugproduces a decreased effect or increasingly larger doses are required to to obtain the effect observed with the previous/original dose.

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Important definitions

Intoxication: a reversible syndrome caused by a specificsubstance, that affects one or more of the following mental functions: memory, orientation, mood, judgement, and behavioural, social or occupational functioning.

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Withdrawal: a substance specific syndrome that occurs, afterstopping or reducing the substance that has been used regularly over prolonged period. It is characterised by physiological signs and symptoms in addition to psychological changes like disturbances in thinking, feeling or behaving. Also known as abstinence or discontinuation syndrome.

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Important definitionsCross tolerance: refers to the ability of one drug to besubstituted for another, each usually producing the same physiological and psychological effect. Also known as cross- dependence.

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Co-dependence: term used to refer to family membersaffected by or influencing the behaviour of the substance abuser.

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Enabling: the act of facilitating the abuser's addictivebehaviour. Also includes the unwillingness of a family member to accept addiction as a medical-psychiatric disorder or todeny that the person is abusing.

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Important definitions

Denial: The family member often behave asthe substance use that is causing obviousproblems, are not really problems.

if•

Neuroadaptation: neurochemical orneurophysiological changes in the body thatresult from repeated administration of a drug.

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Alcohol Use DisorderDr Priyal Desai

2nd year resident, Dept. Of Psychiatry

Alcoholism•

Alcoholism is characterized by:A prolonged period of frequent, heavy alcohol use.The inability to control drinking once it has begun.

Physical dependence manifested by withdrawal•

symptoms when the individual stops using alcohol.

Tolerance, or theachieve the sameA variety of socialhol use.

need to useeffects and/or legal

more and more alcohol to

problems arising from alco

Types of liquorEthyl alcohol (ethanol) is the commonest form of alcoholused as a beverage.A single drink is usually 12g of ethanol.

Country English

Desi Tharra Taadi

Mosambi Narangi Mahua Anguri Kaju

Fenny Laththa

Beer(5%) Whiskey(40-45%)

Wine (12%) Vodka(40%)Rum (40%) Gin(42%)

Tequilla(38-40%)Champagne(10-12%)

StatisticsIn Asia, India is the highest consumer whiskey(40%).

of•

For India, out of a total population of 132 crores:•

-approx. 40 crores (30%) drink alcohol regularly

-4 crores (3% of total population) are alcoholics

States that have banned the use of alcohol: Gujarat,Manipur, Nagaland, Bihar and UT Lakshwadeep.

EpidemiologyRace: whites and Hispanics have higher blacks have lower

chances,•

Gender: males>females•

Region and urbanisation: < in western countriesmore in large metropolitan cities(56%)than non-metropolitan (46%)

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Education: higher in college degree students thanpeople with less than high school education

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Standard drinks• A standard drink is defined as 3IU of alcohol. It is different in

quantity for different types of drinks. For India, onecorresponds to 10ml of absolute alcohol.

standard drink

• Vodka, Gin, Tequilla, Rum and whiskey: 30 ml

• Beer: 330 ml (regular)

• Champagne: 100ml

• Wine: 125 ml

• Spirits : 30 ml

Definitionsor safe pattern of drinking:Normal•

-not more than 6 IU per day

-not more than 21 IU per week

Not more than 5 days per week

Binge drinking : pattern of drinking characterised•by drinking more than the intended quantitylasting for more than the intended time.

Etiology

Social factors•

Religious factors•

Psychological factors•

Genetic factors•

Etiology (cont.)

Psychological theories:use of alcohol to reduce•

tension and psychological pain, and feel power

However, in high doses, especially at fallingblood alcohol levels, most muscle tensions andnervousness are increased.

•

Psychodynamic theories:•

Etiology (contd.)

Behaviour theories: rewarding effects of alcohol•

Sociocultural theories: Jews, Irish, 40% risk ofbecoming alcoholic due to these.

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Types of alcoholismAlcoholism is classified in various ways•

addiction, can quit, no withdrawal symtoms

can quit, withdrawal seen

Alpha Earliest stage, to relieve pain, can control drinking

Beta Heavy drinkers, drink daily, physical symptoms, no

Gamma Loss of control in drinking, physical dependence,

Delta Physical dependence, withdrawal seen, can't quit

Epsilon

Final stage of drinking, continual and insatiable urge to drink (craving) , compulsive drinking.

Types of alcoholism• Anti social : early onset, predominantly men, poor

prognosis, close relation with anti social personality

• Developmentally cumulative: primary tendency for alcoholabuse that is exaggerated with cultural expectations.

• Negative-affect alcoholism: more common in women thanmen, for mood regulations and to ease relations

• Developmentally self-limited alcoholism: frequent bouts ofconsuming large quantities of alcohol, become less frequent with age and responsibility

Types of alcoholism-dependence

Type A-late onset, less childhood risk factors,relatively less chances for dependence, fewalcohol-related problems.

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Type B- early onset, more childhood risk factors,severe dependence, strong family history, long history of alcohol abuse and treatment, more alcohol related health problems.

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Types of alcoholism

Young adult -32%, largest subtype, average age is 24 yrs, rarely seekhelp, drink less frequently, more chances of binge drinking.

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Young anti-social- 21% They are 26 years old, on average. More thanhalf have antisocial personality disorder, start drinking at 15 and became alcoholics by 18 -- earlier than other subtypes. They are more likely to have other substance use too

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Functional: 19%, middle-aged, working adults with stable relationships,educated, and higher incomes. They tend to drink every other day, upto five or more drinks on drinking days.

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Immediate familial:19%, half have close relatives who are alcoholics.Alcoholics in this subtype typically began drinking by 17 and became alcoholics in their early 30s.

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Chronic severe: rarest subtype, accounting for about 9% of U.S.alcoholics. This subtype mainly includes men, has the highest divorce rate, and frequently includes users of illicit drugs.

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Psychiatric co-morbidities

Mood disorders: 40-50% meet criteria for majordepressive disorder

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Anxiety disorders: 25-50% with AUD meetcriteria for anxiety disorder

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Suicide: 13% chances of committing a suicide•

Neurochemical effectsof alcohol

Alcohol has major effects on most neurochemicalsystems, with opposite actions during intoxication and withdrawal.

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Intoxication and subsequent craving involvechanges in dopamine, with effects on thepleasure centers

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Alcohol also causes an increase in theconcentration of serotonin in the synapse upregulates serotonin receptors.

•

and

Neurochemical effectsof alcohol

Effects of alcohol, especially actions on the GABA-receptor (GABA), enhance the acute sedating, sleep-inducing, anticonvulsant, and muscle-relaxing properties of alcohol

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For the NMDA receptors, it has dampenedeffects during intoxication and heightened activityduring alcohol withdrawal.

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AbsorptionAbsorption: About 10% of alcohol ingested is absorbed into the stomach, rest 90% is absorbed in the 2nd part of duodenum.

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In most cases, higher alcohol concentration, faster is the rate ofabsorption. However, beyond a certain concentration, the rate decreases due to delayed passage of alcohol from stomach to small intestine.

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Maximum absorption rate is seen with a beverage containingapprox. 20-25% alcohol, and rate decreases with beverages containing 40% or more alcohol

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Absorption increases if the drink is taken empty stomach and viceversa.

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AbsorptionPeak blood concentration is reached within 30-90•

minutes, usually within 45- 60 minutes.

Alcohol is uniformly absorbedhence tissues containing highabsorb more alcohol.

in body waterproportion of water

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The intoxicating effects are higher when theblood alcohol is rising than when it is falling.(Mellanby effect)

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Metabolism• 90% alcohol is metabolised through oxidation in

remaining is excreted unchanged by lungs andkidneys.

liver,

• Rate of metabolism is 10-34mg/dL per hour.

• Alcohol is metabolised by two enzymes: alcoholdehydrogenase(ADH) and aldehyde dehydrogenase.

• Alcohol is converted into acetaldehyde catalysed byADH.

Metabolism

Acetaldehyde is a toxic substance and causes•

Hence it is converted into acetic acid catalysedby aldehyde dehydrogenase.

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Women have lower levels of ADH which could bea reason for their intoxication more than menafter drinking the same amount of alcohol.

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Acetyl COA is then converted to water and carbondioxide that is released via the kidneys and lungs.

Blood alcoholconcentration(BAC)

It is theunits of alcohol

percentage of ethanol in the blood in•

alcohol per volume of bloodper mass of blood.

or mass of

The blood alcohol legal limitalcohol in blood

in India is 0.03%•

Impairments acc to BAC•

Intoxication

Acc. To DSM-V:•

Recent ingestion of alcohol, maladaptivebehaviour and one of the following:

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Slurring of speech, in coordination,ataxicgait,nystagmus, impaired attention concentration,stupor or coma

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Effect of variousconcentrations of alcohol:

• At higher levels, the following can be manifested:

• 20-30mg/dL-slowed motor performance and decreased thinkingability

• 30-80mg/dL-increased motor and cognitive deficits

• 80-200mg/dL- in coordination and judgement errors, mood lability

• 200-300mg/dL- nystagmus, slurring of speech, blackouts

• >300mg/dL- impaired vital signs

• >400mg/dL- respiratory failure, coma, death

Withdrawal• Cessation of alcohol use which was heavy and

prolonged.

• Classic sign of withdrawal is tremulousness.

Symptoms and signslast intake

autonomic hyperactivity

withdrawal)

Duration from

6 to 8 hours Tremulousness, irritability, GI symptoms,

8 to 12 hous Psychotic and perceptual abnormalities

12 to 24 hours Seizures (can occur within first 72 hours of

Up to 72 hours Delirium tremens

Treatment• Withdrawal seizures: stereotyped, GTCS, more than

one seizure can occur within 3-6 hours of first seizure.

• Status epilepticus is rare (<3%)

• Treatment does not require anti-convusants, however mostpatients receive them, to be on the safer side.

• Benzodiazepines are primarily used to control withdrawalsymptoms.

• Drugs like carbamazepine can also be used in daily dosesof 800mg.

Delirium TremensAlcohol withdrawal tremors with delirium are a seriousmedical emergency.

•

Essentially DT is seen within 1 week after he stops or•

decreases drinking.heavy drinking.

Begins generally after 5-15 yrs of

Best treatment is prevention.•

BZD chlordiazepoxide (50-100mg every 4 hrs)•

Lorazepam IV•

Correct dehydration•

hrs

Drug symptoms dose

Chlordiazepoxide Tremors andtremulousness

Extreme agitation

25-100 mg every 4-6

0.5mg/kg at12.5mg/min IV

Diazepam Mild to moderate agitation

Withdrawalseizures

5-20mg every 4-6 hrs

0.15 mg/kg at2.5mg/min

Lorazepam Hallucinosis

Delirium tremens

2-10 mg every 4-6 hrs

0.1mg/kg at 2mg/minIV

Other effectsBlackouts: it is characterized by memoryimpairment for the period when a person drinking heavily and was awake.

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was

Sleep impairments: alcohol helps in sleepingquickly, but if it exceeds 2-3 drinks per evening,sleep pattern is impaired.

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Cerebellar degeration: unsteady gait, nystagmus•

Peripheral neuropathy: tingling numbness, pinpricking sensations, cotton-wool sensations

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CNS effectsWernickes encephalopathy: Caused by thedeficiency of vitamin B1(thiamine that helps conduction of axon potential along the axon in synaptic transmission.

•

inand

Manifested as ataxia, ophthalmoplegia,confusion.

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Treatment: 100mg BD or TDS for 1-2 weeks•

CNS effectsKorsakoff’s syndrome: Chronic amnestic disorderthat follows Wernicke’s encephalopathy.

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Cardinal features are: irreversible damage,impaired anterograde memory withconfabulations.

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Treatment: thiaminemonths.

100mg BD or TDS for 3-12•

Hardly recover fully,improve.

but cognitive functions may•

Others

Marchia Fava Bignami syndrome: progressiveneurological disease of alcoholism characterised by corpus callosum demyelination and necrosis.

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Fetal Alcohol syndrome: alcohol intake in womenwho are pregnant or lactating. Alcohol inhibits intrauterine growth and postnatal development leading to microcepaly, malformations of heart,limbs and lungs.

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