Misuse of alcohol

RJ

How many people in the world use alcohol?

2 billion ( a billion is thousand times a

million or 10 to the power 9)

Is alcohol a problem in Sri Lanka?

How does a typical Sri Lankan alcohol user

progress (or deteriorate) in his alcohol
habit?

Starts as an occasional drinker

Then week-end drinker-especially if he is doing a

regular job and gets week-ends of

Regular drinker- ?daily or more or less daily

(may be they still enjoy drinking, start
dram or two)
after sometime they develop...........

with one

What is tolerance?

After a session of heavy drinking can get

black outs or memory blackouts (which
may also occur in occasional drinkers after
a bout of very heavy drinking)
What are blackouts?

After some more time may be years- gets

dependent on alcohol

Once he gets dependent on alcohol, his

behaviour is all around alcohol, how to get
the next drink, how to find the money to get
it, hides alcohol in the bathroom etc

Gets withdrawal efects what are they?

tops up to avoid withdrawal efects,
morning drinking etc.

Alcohol withdrawal
occurs after cessation or reduction of
alcohol use that has been heavy and
prolonged

after days or several hours of above,

develops

1) autonomic hyperactivity e.g. sweating,

tachycardia
2) increased hand tremor
3) insomnia
4) nausea or vomiting

5) psychomotor agitation
6) anxiety
7) grand mal seizures

8) Alcohol withdrawal can be with

perceptual disturbances- visual, tactile or
auditory hallucinations and illusions
Lilliputian hallucinations

Delirium tremens

This is a severe form of withdrawal

syndrome that occurs when the patient is
physically dependent on alcohol. The
features are:

Delirium: clouding of consciousness,

disorientation in time and place, impairment
of recent memory, illusions and
hallucinations, fearfulness and agitation

Tremors are gross (which gives the

condition its name)

Ataxia

Insomnia

Autonomic disturbances (sweating,

tachycardia, raised blood pressure,
dilatation of the pupils)

Hallucinations are frightening and visual

involving Lilliputian people or animals.
Auditory and tactile hallucinations also
occur

Dehydration and electrolyte disturbances

Like in other deliriums the features are

worse at night, lasts about 3-4 days and
then patient sleeps to awake with no
memory for the period of delirium

Mortality is 5%, patients die of exhaustion,

cardiac complications and sometimes due to
seizures

Treatment has to be prompt

high dose chlordiazepoxide , may need
100
mg per day in divided doses, this is gradually
reduced over the next few days, may be
seven days, depending on the clinical state

Oral thiamine and very often parenteral high dose B

vitamin preparations are given, e.g. polybion in saline
infusion

Metoclopramide may be needed if nauseated

Diazepam 10 mg is indicated in addition to

chlordiazepoxide if seizures occur

May occasionally need an antipsychotic but better to

avoid.

Anticonvulsants are not indicated

Types of alcohol
spirits high alcohol content as they are
obtained from distillation e.g. whiskey,
arrack
fermented drinks low alcohol content e.g.
beers and wines

Is alcohol good for us?

What is a safe level of alcohol drinking?

for males 21 units per week
for females 14 units per week
What is a unit?
half a pint of beer 375 ml can
one wine glass of wine
dram of arrack- (bar measure of spirits)

Drinking alcohol above the recommended

level is called Hazardous drinking

Harmful drinking drinking that has already

Alcohol abuse
caused physical, mental
or social damage to the
user

Alcohol dependency

1)
2)
3)
4)
5)
6)

7)

Seven features of dependence on alcohol (at least three

are required present during previous year)
Tolerance
Withdrawal efects
Alcohol taken in larger amounts for longer periods
Loss of control, though trying to cut down
Life revolves around alcohol
Important social, occupational or recreational activities
are given up because of alcohol
Continued use despite realisation that it has caused
physical or psychological problems

Alcohol dependence
syndrome

Heavy drinking can lead to a dependence

syndrome

Due to liver damage tolerance falls and the

drinker can not drink the amounts he used to
drink

They get withdrawal efects after a few hours

and have to take alcohol to avoid the
withdrawal symptoms, thus they drink every
few hours of the day (relief drinking)

They start with morning drinking which is

another feature of the syndrome

Typically they hide bottles in various places

so that they can top up and not allow
others to notice their frequent drinking

They start drinking the cheapest and

strongest drinks to get their requirement at
a lesser cost

They develop further physical, social and

psychological damage due to this drinking

If they manage to cease drinking they improve

physically sometimes quite markedly, eating
and sleeping well

If they take even one drink after abstinence

they are vulnerable and may get back to earlier
pattern of uncontrolled drinking very soon

Harmful physical efects of alcohol

Gastrointestinal gastritis, peptic ulcer,

pancreatitis, malnutrition and vitamin
deficiencies, fatty liver, hepatitis, cirrhosis,
carcinoma of liver, oesophagus, lip, tongue,
pharynx and larynx

Neurological peripheral neuropathy,

cerebellar degeneration, dementia and epilepsy

Cardiovascular increase of blood pressure,

cardiomyopathy, thiamine deficiency can
lead to beriberi

Skeletal muscle wasting

Afects the developing fetus fetal alcohol

syndrome

Psychosocial efects

Work related- poor performance, sickness

absence, getting sacked

Interpersonal losing friends, getting into fights

Marital problems neglect of family, domestic

violence, Othello syndrome

Suicide is a risk

Toxic nutritional conditions

1) Wernickes encephalopathy
acute confusion, ophthalmoplegia,
nystagmus, ataxia
2) Korsakofs syndrome
3) Alcoholic dementia

Perceptual disturbances

Transient hallucinations
no other features of DTs

Alcoholic hallucinosis
distressing auditory hallucinations in
clear
consciousness, sometimes for days

Screening for alcohol use problems

CAGE
c cut down
a annoyed
g guilty
e eye-opener
(two or more positives identify problem

AUDIT
Alcohol Use Disorder Identification Test

drinkers)

Treatment and
management

Detoxification
could be planned or unplanned
Benzodiazepines are used generally in
high doses
e.g. chlordiazepoxide
High dose vitamin B oral or parenteral

Relapse prevention

Psychological treatments
CBT
group therapy
alcoholic anonymous (AA)

Pharmacological treatments
disulfiram (antabuse) how does it act?
can it be given without patients knowledge?
acamprosate it reduces drinking in dependent
animals. It is said to reduce craving for alcohol in
patients with alcohol
dependence
naltrexone is used in some countries as
or implants

tablets

In psychological treatments Stages of

Change concept put forward by DiClemente
and Prochaska is used

They proposed that deciding to stop using a

substance is a behavioural change which
occurs in a series of steps rather than one
leap

There are five stages

1) Precontemplation
denial of the problem, rejects treatment or advice
trying intervention at this stage is
unsuccessful

2) Contemplation
acknowledges there is a problem but not sure
whether it needs a change, receptive to education
and will weigh up pluses and
minuses

3) Preparation
getting ready to change, will try to find
out
how to do it, e.g. ask others, read about it

4) Action
changing behaviour, seeks help

5) Maintenance
maintaining the behaviour change,
temptation

avoiding

after maintaining the behaviour change for sometime,

may

6) Relapse
slips back into Precontemplation stage
Cycle starts again

This cycle of behaviour change is said to apply to many

people with problems of a substance misuse like alcohol,
opioids, benzodiazepines, solvents, cannabis etc.
First described for tobacco smokers.

Why do people drink alcohol? (aetiology)

How successful are we in the treatment of

alcohol misuse?

What actions would reduce alcohol misuse

problems in the community?