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Psych - Alcohol use disorders

Terms in this set (56)

Role of alcohol in various cancers
Alcohol causes about 20-30% of esophageal cancer, liver cancer, cirrhosis of the liver, homicide, epileptic seizures, and motor vehicle accidents worldwide

In the U.S., it accounts for 85,000 deaths per year

Economic costs in U.S. ~$200 billion per year
Alcohol related disorders are divided into two main groups:
Alcohol induced disorders

Alcohol use disorders
Alcohol induced disorders = (4)
Alcohol intoxication
Delirum
Alcohol withdrawal
Alcohol induced amnestic disorders
Alcohol use disorders = (2)
Alcohol abuse
Alcohol dependence
Alcohol Related Disorders

epidemiology part 1
Lifetime prevalence for alcohol use disorders is ~14.6%

10 million American adults meet criteria for alcohol abuse

8 million American adults meet criteria for alcohol dependence

Men have higher rates of abuse and dependence

More than half of all families report having at least one close relative with a drinking problem
Alcohol Related Disorders

epidemiology part 2
Highest rates of alcohol use, heavy/binge use , and alcohol use disorders are between 18 and 29 year olds

About 11 million underage people (12-20 yo) report drinking in the past month, with 10 million of those either drinking heavily or binging

Early exposure to alcohol is an independent risk factor for developing alcohol dependence
Alcohol Related Disorders

epidemiology part 3
National Epidemiologic Survey on Alcohol and Related Conditions (NESARC)

For people drinking before the age of 14, 47% had alcohol dependence within their lifetime

Alcohol use is highest in Caucasians

Young non-African American males are about twice as likely to have an alcohol use disorder as young African American males

Use disorders usually decline with age, except with African American women (increase with ages 30-44)
Alcohol in psych issues
Heavy, chronic alcohol use can mimic psychiatric disorders with psychosis, mood changes, and anxiety

These psychiatric symptoms resolve with abstinence

In order to make the diagnosis of an independent, comorbid psychiatric disorder, the patient needs at least 4 weeks of sobriety
The acute effect of a given amount of alcohol on an individual will vary depending on a number of factors: (6)
Weight (higher weight, less impact).

Gender (women tend to be affected more).

Genetics (variations in absorption and metabolism).

Rapidity of consumption (faster consumption leads to higher levels).

Presence of food in the stomach (slows absorption).

Tolerance (those who consume alcohol regularly develop a tolerance to the effects and metabolize alcohol more rapidly).
BAC =
BAC = blood alcohol concentration or content - expressed as grams of alcohol per 100 grams of blood

Alcohol level can also be expressed as mg/dL which is equivalent to the BAC times 1000

Concentration of alcohol in the breath correlates with alcohol levels, but is lower by a factor of ~ 2100; "breathalyzer" readings are an estimate of the blood alcohol level using this factor.
What defines a "drink"
is defined as 12 oz of beer or wine cooler (a standard bottle or can), 5 oz of wine (a standard glass), or 1.5 oz of distilled spirits (a shot glass); each contain about 0.5 fluid ounces or 12 grams of alcohol
BAC considered intoxicated? General rule of thumb for consumption?
A BAC of 0.08% (80 mg/dL) or higher is considered intoxicated.

General rule of thumb - 2 standard drinks increase the average person's blood alcohol concentration by roughly 50 mg/dL (0.05%), therefore one would generally need to consume at least 3 drinks to be over this threshold.
Alcohol typical rate of metabolism?
Rate of metabolism of alcohol varies widely between different individuals, but is approximately 10-15 mg/dL per hour

Chronic alcohol abusers generally metabolize it at a higher rate of about 20-30 mg/dL per hour.
Risk of death at what BAC?
Risk of death with blood alcohol concentrations over 300 mg/dL

Median lethal concentration (LC50) for the non-dependent population is 450 mg/dL

There have been reports of alcoholics surviving with concentrations as high as 1500 mg/dL
Blood Alcohol Levels and Symptoms
Clues of alcohol use disorder:
Smell of alcohol on breath, slurred speech, ataxia

Drinking before a doctor's appt.

If abstained before appt., may be in withdrawal with tremors, diaphoresis, tachycardia, and elevated BP

History of multiple traumatic injuries

Work or family problems

Depression, anxiety, sleep disorders

Gastrointestinal problems

Sexual dysfunction

Heavy cigarette smoking

Family history of alcoholism
Alcohol coma =
Rare occurrence with extremely large amounts of alcohol plus another drug

Medical emergency

College age youth in drinking contests
Alcohol withdrawal syndrome

Hallmark?
generalized tremor
Alcohol withdrawal syndrome

3 symptom clusters =
Autonomic hyperactivity -

Neurological - seizures within 12-48 hours after last drink

Delirium tremens (DTs)
Alcohol withdrawal syndrome

What is autonomic hyperactivity?
tremulousness, diaphoresis, tachycardia, nausea, vomiting, anxiety, agitation; appear within a few hours of last drink, peak within 24-48 hours, and resolve after 3-5 days
Alcohol withdrawal syndrome

What is delirium tremens?
Delirium tremens (DTs) - alcohol withdrawal delirium

Can be fatal if untreated - deaths in 10%; 25%
in patients with medical or surgical complications

Generally occur within 24-72 hours after abstinence begins

Disorientation, tremor, marked wakefulness, fever, visual and tactile hallucinations, autonomic hyperactivity
Alcohol withdrawal syndrome

DT's treatment
Prevention!

Immediate thiamine (100 mg IV), followed by 100 mg IM daily for 3 days

Folic acid 1 mg orally or IM daily

Benzodiazepines

Haloperidol 5-10 mg IM or orally added and repeated every 1-2 hours for agitation and psychosis
Wernicke-Korsakoff Syndrome =
Thiamine deficiency

Wernicke's encephalopathy

Sudden onset of ophthalmoplegia and ataxia

Confusion, disorientation, somnolence

Confusion/memory problems and ophthalmoplegia can be reversible with prompt treatment.
Wernicke-Korsakoff Syndrome

Tx
thiamine 100 mg IV and 1 mg folic acid IV immediately; followed by daily dosing
Wernicke-Korsakoff Syndrome

Korsakoff's psychosis =
(confabulating psychosis or alcohol induced amnestic disorder)

Impaired memory in alert and responsive patient

End stage of chronic alcoholism

Hallucinations or delusions are rare

Diminished verbal output; limited understanding/lack of insight

Memory loss - retrograde with inability to recall the past, and anterograde with inability to retain new information

25% recover completely, 25% no recovery, and the rest partial recovery

Affected structures are the dorsal nucleus of the thalamus and the hippocampus
Medical Complications of Alcohol Use Disorders = (just a few examples)
Alcohol = how much is associated with a mortality increase?
Mortality is increased beyond 2-3 drinks/day for women and 3-4 drinks/day for men
DSM-V alcohol use disorder criteria =
alcohol use disorder (no abuse or dependence but uses specifiers of severity of symptoms:

Mild - presence of 2-3 symptoms
Moderate - presence of 4-5 symptoms
Severe - presence of 6 or more symptoms
Alcohol dependence definition =
A maladaptive pattern of drinking, leading to clinically significant impairment or distress, as manifested by 3 or more of the following occurring at any time in the same 12-month period: See next question
DSM-V: What are the alcohol dependence signs and symptoms?
1) Tolerance (the need for markedly increased amounts of alcohol to achieve intoxication or the desired effect; or a markedly diminished effect with continued use of the same amount of alcohol)

2. Withdrawal

3. Impaired control (the persistent desire, or one or more unsuccessful efforts to cut down or to control drinking; drinking in larger
amounts or over a longer period than intended)

4. Neglect of activities (e.g., giving up or neglecting important social, occupational, or recreational activities because of drinking)

5. A great deal of time spent in activities necessary to obtain, to use, or to recover from the effects of drinking

6. Continued drinking despite knowledge of having a persistent physical or psychological problem that is likely to be caused or
exacerbated by drinking
DSM-V: Alcohol abuse criteria
A maladaptive pattern of drinking, leading to clinically significant impairment or distress as manifested by at least one of the following occurring within a 12-month period:

1. Recurrent use of alcohol resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to alcohol use; alcohol-related absences, suspensions, or expulsions from school; neglect of children or household)

2. Recurrent alcohol use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by alcohol use)

3. Recurrent alcohol-related legal problems (e.g., arrests for alcohol-related disorderly conduct)

4. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol (e.g., arguments with spouse about consequences of intoxication) (Never met criteria for alcohol dependence.)
Limits of "healthy alcohol use" for men and women:
Men = 2/day, 14/wk, 4/occasion

Women = 1/day, 7/wk, 3/occ
Alcohol Use Disorders

Etiology? Risk factors?
Epigenetics - genetic, biological, environmental

Initiation of alcohol consumption
- Main factor is parents' drinking status, siblings, friends, and environment/culture/geography

Patterns of consumption after drinking starts
- Genetic factors, siblings, peers, regional culture

Fourfold increase in risk for alcohol dependence among relatives of people with alcohol dependence

Risk increases with increases in the number of close relatives with alcohol dependence

Genes influence phenotypes - impulsivity, disinhibition, sensation seeking

Genes influence enzymes - alcohol dehydrogenase, aldehyde dehydrogenase

Genes influence level of response to alcohol's effects
Alcohol Use Disorders

What is a "dual diagnosis?"
Refers to patients who have a co-morbid psychiatric disorder and substance use disorder

Highest rates of alcohol dependence and anxiety disorders, followed by alcohol dependence and other drug use, then alcohol dependence and affective disorders

Both diagnoses need treatment in order to achieve best possible outcome

Remember, in order to make the diagnosis of an independent, co-morbid psychiatric disorder, the patient needs at least 4 weeks of sobriety
Alcohol Use Disorders

General pathophysiology
Alcohol affects neurotransmitters by causing either neuronal excitation or inhibition

Receptors adapt to the presence of alcohol resulting in neurotransmitter imbalances

These imbalances can then produce agitation, sedation, depression or other mood/behavioral changes, or seizures
Alcohol Use Disorders

Pathophysiology: glutamate role
Glutamate (major excitatory neurotransmitter) receptor sites in hippocampus are increased by chronic, heavy alcohol use

This may affect memory and account for alcohol related "blackouts"

Glutamate receptors then adapt to the presence of alcohol and overactive during alcohol withdrawal - this can lead to seizures
Alcohol Use Disorders

Pathophysiology: GABA role
GABA (gamma-aminobutyric acid) - major inhibitory neurotransmitter -

Alcohol increases its effects with resulting sedation

Chronic, heavy alcohol use causes a gradual decrease in GABA receptors
Alcohol Use Disorders

Screening tools
The 2 most widely used screening tests are the AUDIT and the CAGE questionnaire

CAGE questions are the best studied screening tool for alcohol use disorders

CAGE lacks sensitivity to detect problem drinking but can detect alcohol dependence

AUDIT has been validated across a number of cultural and ethnic groups

SASQ - single alcohol screening question
Alcohol Use Disorders

AUDIT screen =
AUDIT consists of 10 multiple-choice questions, each assigned a score, which is added at the end; a score of eight or more is considered highly indicative of an alcohol problem.

The first 3 items of the questionnaire, which ask about the quantity and pattern of alcohol consumption (the "AUDIT-C"), are just as sensitive and specific as the full test for detecting heavy drinking and alcohol abuse or dependence
Alcohol Use Disorders

AUDIT-C positive result?
"AUDIT-C" - a score of 3 or more has:

Sensitivity of 98% for heavy drinking

Sensitivity of 90% for alcohol abuse or dependence

Specificity of only 60% (i.e., 40% false-positive rate)

Using a cut-off of 4 increases the specificity to 72%
SASQ =
SASQ - single alcohol screening question

A recent study suggests that the single question - a version of the third question on the AUDIT - performed almost as well as the AUDIT for detecting harmful drinking.

The question is: "When was the last time you had X or more drinks in one day?" (X = 4 for women, 5 for men).

A positive answer (for the previous three months) had a sensitivity of 85% and specificity of 82% for hazardous or harmful drinking
CAGE =
Cut down
Annoyed by ppl criticizing drinking
Guilty about drinking
Eye opener
CAGE results
When using a cutoff of two or more positive answers, the sensitivity was 74% and specificity 91%

Using a cutoff of one or more positive answers increased the sensitivity to 89% while lowering the specificity to 81%

In primary care patients, the first question (CUT DOWN) was the most sensitive (63%) and seemed to perform the best over a variety of demographic subgroups, but had the lowest specificity (84%)

The last question (EYE OPENER) is the most specific (95%), but is relatively insensitive (21%)
AUDIT score zones and treatments
What is a brief intervention?
Can be effective at reducing alcohol consumption

More effective than no intervention

Effect may last for up 4 years beyond the intervention

Recommended for patients who drink to excess but do not meet criteria for alcohol abuse/dependence

Focused assessment with brief advice from health care provider

Consists of 4 or less sessions lasting from a few minutes to 1 hour each

Can be conducted by a provider who is not an addictions specialist

Even brief advice (5-10 minutes), delivered by physicians and nurse practitioners as part of routine primary care, has been shown to be effective
Brief intervention: Effective counseling generally has three components =
feedback, advice and goal-setting. The 5 A's are:

Assess current drinking with a brief screening tool ("Your results show...")

Advise sensible drinking limits and educate regarding risks ("I would recommend that you cut down or stop...")

Agree on individual goals for reducing alcohol use or abstinence ("It is quite possible for you to achieve this...")

Assist patient with acquiring self help skills, motivation, and supports ("There a number of things you might do...")

Arrange follow up and repeat counseling or refer for specialty treatment if indicated
Treatment for Alcohol Use Disorders

Features?
Unlike patients who are heavy or at-risk drinkers, patients with alcohol dependence have better outcomes when seen by addiction specialists

Brief intervention/counseling has shown not to be effective for these patients

Respectful confrontation of problem and empathy

Hope and help
Treatment for Alcohol Use Disorders

Intensive inpatient or extensive outpatient interventions:
There are a variety of modalities available which can involve individual and group therapy, family therapy, behavioral therapy, and pharmacotherapy

Duration and continuity of care are important determinants of treatment success

90 days or more of treatment is associated with better long term outcomes

40-60% of patients treated for alcohol addiction remain abstinent after one year

Another 15% have clinically significant improvement in their alcohol use problems
Treatment for Alcohol Use Disorders

Inpatient vs. outpatient alcohol detox
For the alcohol dependent patient, prevention and treatment of alcohol withdrawal is important

Mild-moderate alcohol withdrawal (no impending delirium tremens [DTs] or recent seizures) can be managed as outpatient
Treatment for Alcohol Use Disorders

DTs
Risk of DTs is greatest in patients with h/o DTs or other alcohol withdrawal complications

Other risk factors for DTs: elevated BP, increased HR, older age, medical comorbidities
Indications for inpatient alcohol detox: (6)
Moderate to severe withdrawal

Previous seizures or delirium tremens

Inability to cooperate with daily follow-up

Comorbid medical or psychiatric illness that requires hospitalization

Inability to take medications by mouth/persistent nausea and vomiting

Unsuccessful previous attempts at outpatient detoxification
Treatment for Alcohol Use Disorders

Alcohol detoxification regimen (meds)
Treatment for Alcohol Use Disorders

Pharmacological interventions: features?
Used as adjunct to self-help programs and other psychosocial therapies

No drugs have shown to improve long term clinical outcomes,

They have modest efficacy in research studies done

But they are FDA approved for treatment of alcoholism
Pharmacological interventions for Alcohol Use Disorders
Treatment for Alcohol Use Disorders

Pharmacological interventions

Non-FDA approved?
topiramate (Topamax) which affects GABA transmission.

Two randomized-controlled study of this anti-seizure medication at doses of 200-300 mg/day have reported a significant reduction in alcohol consumption and increase in abstinence over a 12-14 week period
AA =
Alcoholics Anonymous and long-term support

Patients require ongoing treatment

AA has been shown to improve outcomes with helping to achieve and maintain abstinence

Attendance at meetings is associated with improvement in drinking behaviors
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