Alcoholism

Related factors and treatment

Dr. Don Goodwin (1991)

Alcoholism involves a compulsion to drink, causing damage to self & others.

Bio/Psycho/Social Model

1) Individual who responds to alcohol in a certain way. Positive reward. 2) Personality characteristics that encourage use. Impulsiveness. 3) Member of social group where

A) pressure to drink. College Fraternity. B) confusion over drinking ground rules.

Physiological factors

Biological susceptibility Genetic evidence Family history Children of alcoholics (COA)

If father alcoholic,
25% sons affected 5-10% of daughters

Genetic evidence

Twin studies MZ 100% genes DZ 50% genes Reared together Alcoholism in

55% MZ twins 28% DZ twins

Males particularly susceptible

Male limited. TYPE II alcoholism. More severe, early onset. Many negative consequences. Trouble with law, at school, on job. Environment plays less of a role but can lessen the severity. Adopted COAs did better than those raised with alcoholic parent.

Milieu limited. TYPE 1

All women and 75% of men. Less severe, later onset. May not be treated. Personality factors important.

Reward seekers. Psych dependence.

Environment plays key role. Family and social groups. Intoxication as recreation. Good time depends on drinking.

What is inherited?

High initial tolerance. Different rate of metabolism. Alcohol -> acetaldehyde -> acetate -> CO2 and H20 COAs higher levels of acetaldehyde. Metabolize alcohol quicker. Hence higher tolerance

Acetaldehyde effects

Acetaldehyde may combine with brain chemicals to give opiate-like high Acetaldehyde also toxic to liver and heart. Medical complications

Brain response to novelty

Brain waves to novel stimuli. P3 waves. Less reaction in alcoholics. And in COAs before start drinking. Need more stimulation?

Psychological characteristics

Related to biology? Reward seeking. Impulsive. Easily bored. Risk takers Gregarious Push the limits Act out

Social factors
Alcoholism high in some cultures: Americans, Swiss, Irish, Poles. Low in others: Chinese, Greeks, Orthodox Jews

Alcoholism is low in cultures where

Children learn alcohol is a beverage. Served in dilute forms. Abstain okay. Parents model moderate drinking Getting drunk not seen as comical. Everyone knows ground rules.

Alcoholism is higher in cultures where

No ground rules. Mixed messages from different individuals and groups. Getting drunk okay? Funny? Heavy drinking is encouraged. Drinking a sign of masculinity or adulthood.

Myths

Most alcoholics are skid-row bums Mixing drinks makes you drunk faster Black coffee or cold showers can sober you up Beer drinkers are less likely to become alcoholics Sex is better after a few drinks

What is alcoholism?

World Health Organization (1952)

Alcoholics are those excessive drinkers whose dependence upon alcohol has attained such a degree that it shows an interference with their bodily and mental health, their interpersonal relations and their smooth social & economic functioning.

National Institute on Alcohol Abuse & Alcoholism (1991)

1. I have often taken a drink when I get up in the morning. 2. I deliberately tried to cut down or quit drinking but couldnt. 3. Once I started drinking it was difficult to stop before becoming intoxicated. 4. I have had a quick drink when no one was looking. 5. I skipped meals when drinking.

6. Ive woken up not remembering things I did while drinking. 7.I lost a job or nearly lost one because of drinking 8. My drinking contributed to getting hurt in an accident. 9. A physician suggested I cut down on drinking 10. I have missed work/school because of a hangover.

Stages of Alcoholism

Introductory Stage Early, Forewarning Stage Middle Crucial Stage Final Chronic Stage

Conditions of Alcoholism

Consumption of large quantities over an extended period. Psychological dependence Physical addiction Alcohol-related problems

Effects of alcohol

Short-term (individual) Long-Term (individual) Social Effects Crime & Alcohol

Social Profile

Gender & Age Race & Ethnicity Religious Affiliation Socio-economic status Region

Theories of Alcoholism

Genetic Theories: A gene Blushing response The Alcoholic Personality Sociological Theories degree of fit

Controlling alcohol use & abuse

Legal measures Prohibition Age limits Therapeutic approaches AA Rational recovery

Health Consequences of Alcohol Use

Increased risk of cardiovascular diseases

(Coronary Heart Disease, Stroke, Hypertension)

Increased risk of cancer:

(liver, stomach, colon, pancreas, breast, mouth, throat)

Impaired immune system Malnutrition Reproductive problems

Behavioral Consequences of Alcohol Use

Contributes to 50% of all motor vehicle fatalities Contributes to unsafe sex and increased risk of AIDS Contributes to risky behavior and accidental death

Social Consequences of Alcohol Use on Campus

80% of campus vandalism involved alcohol 70% of violent behavior on campus involved alcohol 75% of men and 55% of women involved in acquaintance rape were under the influence of alcohol

Academic Consequences of Alcohol Use

40% of poor academic performance at college has been linked to drinking 7% of first year dropouts are related to alcohol Alcohol intake is inversely related to GPA

Rates of Drinking on College Campuses

(Data from 17,542 students from 140 Colleges)

Non-drinkers Occasional Drinker Binge Drinker *

MEN 15% 35% 50%

WOMEN 16% 45% 39%

* Binge drinking was defined as having 5 drinks in a row at least once every 2 weeks.

Attitudes and Perceptions toward Alcohol on Campus

95% of students believe that the average student drinks alcohol weekly 30% of students indicated they would prefer NOT to have alcohol at parties

Why People Start Drinking

Peer pressure Need to belong and be accepted Media depiction of drinking Easy access (often at home) Absence of religious attachment Cultural / sociological traditions Social "lubrication" Makes one "feel good"

Trends in Binge Drinking Among High School Youth

% of students who had five or more drinks of alcohol in a row, that is, within a couple of hours, on one or more of the past 30 days
50 40 30 20 10 0 Total Females Subgroup Males 1997 1999 2001 2003

Youth Risk Behavior Survey Youth Online Database

31

Percent

What factors are contributing to the decline in alcohol use and abuse?
Will it continue?

Alcohol Content in Drinks

All three have the same alcohol content despite different volumes

Beer: 4% alcohol X 12 oz Wine: 12% alcohol X 4 oz Whiskey: 40% alcohol X 1.25 oz

= = =

.48 oz alcohol .48 oz alcohol .5 oz alcohol

Factors Determining the Effects of Alcohol

How much was consumed Rate of consumption What is in stomach Presence of carbonation Mood status Sex

Rate of Alcohol Removal

Liver can process .25 oz of alcohol per hour (2 hours to process one drink) Blood Alcohol Content (BAC) decreases by about .015% per hour

Steps to Being a Responsible Drinker

Limit number of drinks Drink less than 1 per 90 min. Sip slowly Eat lots of protein/starch Avoid carbonated drinks Measure drinks carefully Don't drive if intoxicated

How to Help a Friend with a Drinking Problem

Plan a time to talk with person about it Confront behavior - not the individual! Use "I" not "you" in statements Don't judge, blame or lecture Be genuine, kind, and honest Be prepared for denial or rejection Have referral resources available

Managing Alcohol Withdrawal

Identify signs and symptoms of alcohol withdrawal Discuss methods of treating AWS in the inpatient setting

Identify the resources needed for outpatient alcohol detoxification

Clinical Syndrome

Alcohol is a CNS depressant Alcohol hits >30 CNS receptors Withdrawal seems to involve GABA, norepinephrine, & serotonin Signs and symptoms

begin 4-12 hours peak at 24-48 hours resolve in 4-5 days (SORT C)

STEPS IN MANAGING WITHDRAWAL

History and Physical Estimate risk of severe withdrawal and seizures Assess level of withdrawal Implement a protocol Remember the cocktail Follow-up assessment BI or RT or RX when pt comprehending

HISTORY AND PHYSICAL

Withdrawal is often not the only problem

Dont miss head trauma Dont miss GI problems Dont miss metabolic disturbances Dont miss infections Dont miss other intoxications

HOW BAD WILL IT BECOME?

Risk factors for severe withdrawal:

Age >30 Chronic heavy drinking (>12 a day) Hx of generalized seizures Hx of previous withdrawal Other intoxications Presence of comorbid conditions

ASSESS WITHDRAWAL

General Symptoms Autonomic Signs Seizures Hallucinations Delirium and Psychosis

Alcohol and Sedative Hypnotic Withdrawal Stages

General Signs
Stage 1 mild

Hallucinations
no

Delirium
no

Stage 2

moderate

yes
probable

no
yes

Stage 3(DTs) severe

IMPLEMENT A PROTOCOL

BENZODIAZEPINE PROTOCOLS

CIWA-AR FIXED DOSE/TAPER LOADING DOSE/TAPER

ANTICONVULSANT PROTOCOLS

Benzodiazepines are the Treatment of Choice

EVIDENCE

Best to ward off seizures (SORT A) Better than placebo for symptoms (SORT
A)

Better prevention of Delirium (SORT A) Wide therapeutic window (SORT C)

BENZODIAZPINES EQUIVALENTS

Chlordiazepoxide (Librium) 25mg Diazepam (Valium) 10mg Oxazepam (Serax) 15mg Lorazepam (Ativan) 1mg

BZ LOADING

Can be useful if one needs the pt quiet quickly and one can protect the airway Useful for mild withdrawal Still requires reassessment Tapering maybe unnecessary Can be used in outpatient setting

ORAL BZ LOADING PROTOCOL

FIRST DOSE

50 100 mg Chlordiazepoxide 20 40 mg Diazepam If still symptomatic repeat the dose and reassess If calm, asymptomatic plan taper

REASSESS IN ONE HOUR

CONSIDER TAPER OVER 3 5 DAYS REASSESS DAILY

ANTICONVULSANTS II
Tiagabine (Gabitril) investigated 2005

Pilot study (13 patients) Similar results to oxazepam and lorazepam Trend towards less post-detox drinking

Carbamazepine used widely in Europe Recommended in addition to BZ for pts at high risk for seizures

Avoiding Seizures I

Who should receive prophylactic treatment?

Patients

already on anticonvulsants History of epilepsy History of withdrawal seizures Magnesium <1.2 mg %

Avoiding Seizures II

Prophylactic Medication:
Carbamazepine is preferred over phenytoin Give as early as possible Dosage: 100 mg every 2 hours x 4 doses Then 200 mg every 6 hours x 7 days (SORT ?)

THE COCKTAIL

THIAMINE MVI WITH FOLATE MAG SULFATE ONLY IF LOW IV FLUIDS?

REASSESSMENT I

MUST BE DONE IN ONE HOUR NURSING TASK IF ON SYMPTOM-TRIGGERED PROTOCOL STAY IN CONTACT WITH YOUR NURSING TEAM

REASSESSMENT II

Complicated patients with secrets

Reconsider infections, trauma, other intoxications, metabolic problems, & comorbid diseases

Is the withdrawal better or worse? Add magnesium or antipsychotic or carbamazepine? Consultations?

Other Medications Used in AWS

Beta-blockers can control hypertension Clonidine can reduce symptoms and BP Haloperidol (Haldol) or Ziprasidone (Geodon) for persistent psychosis (can be given IM) Hydoxyzine for itching

WHEN THE PT IS BETTER

Brief Intervention? Refer for Treatment? Consider Adjunct Meds

Naltrexone SSRI

For depression For anxiety

Pain Control

OUTPT DETOX I

Make the diagnosis Assess Medical risks

Suicide Risk True seizure disorder Serious acute illness Hx of serious withdrawal

OUTPT DETOX II
Agrees to treatment

Intensive Outpatient At least AA

Assess social support/safety

Will they come back? Will a family member handle meds? Will a friend watch over them?

Management of Asymptomatic Patients

Schedule for re-evaluation in 24 hours If still asymptomatic

Encourage abstinence and AA Consider drug therapy

Follow up in 1 week

SUMMARY

ASSESS AND REASSESS USE BZ EARLY AND OFTEN SYMPTOM-TRIGGERED PROTOCOLS ARE THE BEST STRATEGY DONT JUST DETOX, RX THE UNDERLYING CONDITION CAN DO OUTPTS WITH CARE