Alcohol Use Disorders
Dr. Mohammad Maqbool
ASST. PROFESSOR PSYCHIATRY
Government Medical College, Srinagar
A psychoactive drug is one that is capable of altering
the mental functioning
Four important patterns of use are;-
1. Acute Intoxitation: is a transient condition
following the administration of a psychoactive
substance resulting in disturbance in
- Levels of consciousness
- Cognition
- Perception
- Affect or behaviour
- and other psyco-physiological functions
2. Withdrawal Syndrome
• Characterized by a cluster of symptoms
• Often specific to the drug used
• Develop on total or partial withdrawl of drug
• Usually after repeated high dose and long term use.
3. Dependence
• At least three of the following present
• A strong desire to take the drug
• Difficulties in controlling substance taking behaviour
• A physiological state of withdrawal when the
substance is withdrawn characteristic withdrawal
syndrome.
• Evidence of Tolerance: Increased dose is
needed to achieve effects originally produced by
lower doses.
• Progressive neglect of alternate pleasures or
interests.
• Persisting with substance use despite clear
evidence of harmful consequences e.g.
- Medical complications
- Depressed mood
- Social complications
4. Harmful Use
Characterized by
• Continued use despite awareness of medical/
social effect of the drug being used.
• A pattern of physically hazardous use of drug e.g.
driving during intoxication.
Etiological Factor (Causes)
1. Biological Factors
• Genetic vulnerability
• Co-morbid psychiatric disorders
• Co-morbid medical disorders
• Reinforcing effect of the drug continuation of
drug use.
• Withdrawal effects continuation of drug use.
• Biochemical factors Role of dopamine in the
reward pathway from ventral tegmental area to
nucleus accumbens.
2. Psychosocial Factors
• Curiosity: need for novelty seeking.
• Early initiation of smoking (gateway)
• Poor impulse control
• Sensation seeking
• Low self esteem
• Childhood trauma or loss
• Peer pressure
• Modeling
• Easy availability
• Poor social/family support
• Rapid urbanization
• Intra-familiar conflicts
Pharmacology
• Active ingredient ethyl alcohol (1-ethanol)
• Colorless
• Volatile
• Inflammable
• Sp. Gravity 0.79
• Absorbed rapidly along whole GIT mainly in
duodenum and jejunum.
• 90% metabolised by body mainly by liver.
• Remainder excreted unchanged in urine, sweat and
breath
Alcohol acetyldehyde acetic acid CO2+H2O
Alcohol Aldehyde
dehydrogenase dehydrogenase
Clinical Features and Symptoms of use:
1. Detailed history of intake
2. Patients presents with medical complications
3. Can present with social complications
4. Psychiatric disorders
- Mood disorders
- Psychotic disorders
- Sexual dysfunction
- Sleep disorders
- Amotivational syndrome
Certain Laboratory Markers of Alcohol
Dependence are:
i) GGT (-glutyl-transferace): Increased to above 80IU/L
ii) MCV (mean corpusecular volume): > 92 fl (normal
80-90 fl)
iii) Alkaline phosphatese, AST, ALT, uric acid, CPK,
blood triglycerides.
iv) Body fluid alcohol levels
Urinary Alcohol Diagnostic Equivalent Blood
concentration Alcohol Level
> 120mg % Suggestive 80mg %
> 200mg % Diagnostic 150mg %
CAGE Questionnaire
Four Questions
1) Have you ever had to Cut down on alcohol
(amount).
2) Have you ever been Annoyed by people’s
criticism of alcoholism.
3) Have you ever felt Guilty about drinking.
4) Have you ever needed Eye opener drink (early
morning drink).
A score of 2 or more identifies problem drinkers.
Complications
1. Medical Complications
A. GIT
• Fatty liver, cirrhosis of liver, hepatitis, liver cell
carcinoma, liver failure.
• Gastritis, reflux oesophagitis, oesophageal
varices, mellory-weiss syndrome, peptic ulcer,
carcinoma stomach and oesophagus.
• Melabsorption syndrome.
• Pancreatitis
B. CNS
• Peripheral neuropathy
• Delirium tremens
• Rum fits
• Alcoholic hallucinosis
• Wernickle-Korsekoff psychosis
• Alcohol dementia
• Head injury and fractures
C. Psychiatric
• Mood disorders
• Psychotic disorders
• Sexual dysfunction
• Sleep disorders
• Anxiety disorder
• Amotivational syndrome.
D. Miscellaneous
• Acnae, palmer erythema, parotid enlargement,
ascitis.
• Fetal alcohol syndrome (craniofacial anomalies,
growth retardation, major organ system
malformations), ASD, VSD, microcephaly, mental
retardation.
• Alcoholic hypoglycemia and ketoacidosis.
• Beriberi cardiomyopathy
• Alcoholic myopathy
• Anaemia, thrombocytopenia, vitamin K deficiency
• Hypothermia
• Malnutrition
• Decreased immune function
• Risk for coronary artery disease
• Irreversible testicular atrophy, lower sperm
count, decreased ejaculatory volume
• Infertility
• Spontaneous abortions.
II. Social Complications
• Accidents
• Marital disharmony
• Divorce
• Occupational problems
• Criminality
• Financial difficulties
• Increased incidence of other drug dependence
Acute Intoxication
• CNS depression
• Slowed thinking
• Distractibility
• Dysarthria
• Ataxia
• Incoordination
• Disinhibited behaviour
• Respiratory depression
• Amnesias blackouts
• Coma
• Death (BAC > 400mg%)
- Pathological intoxication small dose of alcohol
intoxication
Withdrawal Syndrome
• Hang over in next morning
• Tremors
• Nausea
• Vomiting
• Weakness
• Irritability
• Insomnia
• Anxiety
• Delirium tremens
• Rum fits
• Alcoholic hallucinosis
Delirium Tremens
• Usually within 2 days of complete
abstenance from heavy drinking.
• Clouding of consciousness
• Disorientation in time & place
• Poor attention and distractibility
• Visual auditory hallucinations
• Tactile hallucinations
• Illusions
• Autonomia disturbances like tachycardia, fever,
sweating, hypertension, pupillary dilatation.
• Psychomotor agitation
• Ataxia
• Insomnia
• Dehydration with electrolyte imbalance.
• Inter-current medical illness like pneumonia,
fractures, liver disease
• Death CVS collapse, infection, hyperthermia.
Rum fits (Alcoholic Seizures)
• Generalized tonic clonic fits
• Usually in heavy drinkers
• Multiple seizures 2-6 at one time
• Status epilepticus
• Delirium tremens follows in 30% cases.
Alcoholic Hallucinosis
• Hallucinations usually auditory during abstinence.
• Occur in clear consciousness
• Usually recovery within one month.
• Very rarely > six months.
Wernicke’s Encephalopathy
• Acute reaction to severe thaimin deficiency
• Usually after persistent vomiting
• Ocular signs like:
- Nystagmus
- Ophthalmoplegia with bilateral external
rectus paralysis.
- Pupillary irregularities
- Retinal haemorrhages
- Papilledema
• Higher mental function disturbance like:
- Disorientation
- Confusion
- Recent memory loss
- Poor attention
- Distractibility
- Apathy
- Ataxia
• Peripheral neuropathy and serious malnutrition
• Neuropathological changes like:
- Thalamus
Neuronal
- Hypothalamus
degeneration
- Mammilary bodies
haemorrhage
- Mid brain
Korsakoff’s Psychosis
• Usually follows Wernicke’s encephalopathy
Wernicke-Korsakoff syndrome
• Amnestic syndrome
• Gross memory disturbances with confabulation
• Insight impaired.
• Neuropathological lesions in bilateral
dorsomedial nuclei of thalamus and mammillary
bodies.
• Severe thiamin deficiency chronic alcohol use.
Treatment
Before starting treatment:
• Rule out any physical disorder.
• Rule out any psychiatric disorder.
• Assessment of motivation for treatment.
• Assessment of social support system.
• Assessment of personality characteristics.
• Current and past social, interpersonal and
occupational functioning.
Treatment can be divided into:
1. Detoxification
2. Treatment of alcohol dependence
1. Detoxification:
- Treatment of alcohol withdrawal symptoms.
- Best way abrupt cessation.
- Uncomplicated withdrawal x 1-2 weeks.
- Symptomatic management of emergent
withdrawal symptoms.
a) Benzodiazepines:
Chlorodiazepoxide 80-200mg/day (divided doses)
Dizepam 40-80mg/day (divided doses)
Higher limit used in delirium tremens.
b) Beta-blockers
Propanolol 40-80mg tid
Atenolol 25-50mg qid
c) Alpha-agonists
Clonidine 0.3-1.2mg/day
d) Carbamazepine 600-1600mg/day
e) Valproate 1000-1200mg/day
Gradually reduced over a period of 2 weeks.
f) Vitamins
Parenterol thiamin 100mg BD x 3-5 days
Oral thaimin 100mg OD x 6 months
g) Hydration 5% dextrose given
h) Low dose antipsychotic if patient is psychotic
Haloperidol 5-16mg/day
• Detoxification can be done both on OPD basis
and IPD basis.
IPD basis must in:
• Signs of impending delirium tremens.
• Psychiatric disorders
• Medical disorders
• Inability to stop alcohol at home
Detoxification is the first step in treatment of
alcohol dependence.
2. Treatment of alcohol dependence:
i) Behaviour Therapy
• Aversion therapy using a subthreshold, electric
shock or an emetic like apomorphine.
• Relaxation therapy like music, play, TV etc.
ii) Psychotherapy
• Patient educated about risks of continuing
alcohol use.
• Asked to resume personal responsibility.
iii) Group Therapy
• Self help groups which support one another.
iv) Deterrent Agents
Disulfiram:
Ethyl alcohol Acetaldehyde Acetate CO2 + H2O
Aldehyde dehydrogenase
Disulfiram inhibits Acetaldehyde levels
Patient educated about + alcohol
Disulfiram alcohol reaction (DAR)
- Flushing - Tachycardia
- Palpitations - headache
- Nausea / Vomiting - Giddiness
Disulfiram : 250-500mg/day x 1st week
250mg/day x maintenance treatment
+ Contraindications
• First trimester of pregnancy
• Coronary artery disease
• Liver failure
• Chronic renal failure
• Peripheral neuropathy
• Muscle disease
• Psychosis in past
Other detterent agents:
• Citrated calcium carbimide (CCC)
100mg/day in divided doses
• metronidizole
v) Anti-craving Agents
• Acomprosate 333mg tablets 2 tablets tid
Interacts with
NMDH (methyl D Aspartate) receptors
Decreases calcium influx
Membrane stabilization
- Naltrexone 50mg/day
- Fluoxetine 20-80mg/day
vi) Other Medications vii)Psychosocial rehabilitation
• Benzodiazepines • Patient put back into the
• society
Antidepressants
• Family support
• Antipsychotic
• • Occupational therapy
Lithium
• • Relaxation therapy
carbamazepine
Prevention of drug addiction in general.
A) Individual Level
- be contended
- trust in God
- be helpful
B) Family Level:
- Help each other
- Give time to your children
- Be moderate towards children
- Do not ignore your children
- Do not give excess money
C) Community Level
• Seminars in schools, colleges
• Media, newspaper, radio, TV
• Friday preachers and religious leaders
• Burn uncultivated charas
• Do not get drugs without doctors prescription.
• Help people in distress
• Recreation like play, music etc.
D) Govt. Level
• Ban cultivation of opoids except for medicinal purposes.
• Strict – drug control
• Stop quacks from practising.
• Decrease syllabus of kids.
• Include hazards of drug abuse in syllabus.
• Help people in distress
• Stop atrocities
• Good psychiatric services at district levels and central
hospitals.
• De-addiction centres at all tertiary hospitals.
