Substance Abuse Disorders: Alcohol

Misuse

Use of a medication or substance that was not prescribed to the individual or use “only for the feeling or experience it caused”

Abuse

Similar to misuse, but with the characteristic that the substance is used for nontherapeutic purposes to obtain psychotropic effect

Addiction

A chronic, relapsing disorder characterized by compulsive drug seeking and use despite adverse consequences

Dependence

Physical → use of a substance that is associated with withdrawal symptoms or a withdrawal syndrome when there is a rapid reduction in exposure or exposure to an antagonist 

Psychological → non-physiological attachment to a substance due to impaired control or compulsion and associated with behaviors to attain the substance 

Tolerance

the need to increase the dose to obtain desired effects

Withdrawal

Signs or symptoms due to the decline in blood concentration of a drug substance or due to the administration of an antagonist

Craving 

A very strong desire for a psychoactive substance of for the intoxicating effects of that substance 

Intoxication

Changes in physiological functioning, psychological functioning, mood states, or cognitive processes, or all of these, as a consequence of excessive consumption of a drug; usually disruptive

disease, treatment, chronic, structural, loss, exposure, external

Addiction: Choice or Disease?

-Concept that addiction is a ________ is supported by its manifestations, course and response to ________ which is comparable with other ____ medical illnesses

-Addiction causes predictable and persistent ________ and functional changes in the brain

-Volume ____ of brain tissue has been found in individuals with substance use disorders

-Only a minority of people who try drugs / alcohol become addicted

-Rationale for those who consider addiction to be a choice → disease expression in substance use disorders requires ________ to a drug

-Challenges to this ideology → other psychiatric disorders also need ________ triggers

history, depression, antisocial

Risk Factors: Biologic

-Genetics → family _______

-Gender

-Mood disorder → major ___________, bipolar disorder

-Personality disorder → _________ or borderline 

childhood, refusal, poverty, teens, mental, parental, good

Risk Factors: Environmental

-Risk Factors

• Aggressive behavior in ___________

• Lack of parental supervision

• Low peer _______ skills

• Drug experimentation

• Availability of drugs at school

• Community _______

• _____ and people with mental disorders are at increased risk of drug use and addiction

-Protective Factors

• Self-efficacy (belief in self-control)

• ________ monitoring and support 

• Positive relationships

• ______ grades

• School anti-drug policies

• Neighborhood resources 

early, increased, experiment, peer, injected

Other Risk Factors

-_____ use

-Increased risk during times of transition → loss of loved ones, going to college, moving

-Adolescence → __________ tendency to experiment with drugs/alcohol. More vulnerable to ____ pressure

-Drugs that are _________/smoked associated with increased addiction potential

relapsing, alcohol, negative, binge, withdrawal, craving

Cycle of Addiction

-Chronic, __________ disorder associated with compulsive _________ drinking/drug use, the loss of control over intake, and the emergence of a ________ emotional state when alcohol/drug is no longer present

-Stages of the Addiction Cycle

• (1) _____/Intoxication Stage → reward, incentive salience, and pathological habits

• (2) Negative Affect / __________ Stage → reward deficits, stressful surfeit

• (3) Preoccupation / Anticipation Stage → _______, impulsivity, executive function

mild, dependence, remission

Severity and Specifiers: DSM-V

-Substance Use Disorder Classification → ____, moderate, severe

-Physical ___________ and withdrawal symptoms are key hallmark symptoms

-Specifiers → in early ________, in sustained remission, on maintenance therapy, and in a controlled environment 

0.08, 5, 4, 14, 7

Alcohol Intake

-Binge Drinking → pattern of drinking alcohol that brings BAC to _.__% or higher

• In the typical adult, that is _ or more drinks for males in ~2 hours and _ or more drinks in females

-Heavy Alcohol Use

• Men → > 4 drinks/day or > __ drinks/week

• Women → > 3 drinks/day or >_ drinks/week

increases, late, conduct, HTN

Alcohol Use Disorder

-Prevalence __________ in middle age, but the age of onset is most commonly in the ____ teens to early-mid 20’s

-Earlier onset noted in patients with ________ disorders and earlier age of intoxication

-Variable course → often perceived as an intractable condition, not commonly the cause

-Increased risk → ___, GI bleed, sleep disorders, MDD, hemorrhagic stroke, cirrhosis, HIV acquisition, and many cancers

stress, male, higher, Asian, decreased

Alcohol Use Disorder: Risk Factors

-Environmental → external ____, which is trauma in childhood, many significant stressors throughout life 

-Genetic → ____ gender, Native American/White ethnicity, rate of condition is 3-4x ______ in close relatives of individuals with AUD

-Decreased risk → ______ ethnicity due to polymorphisms of genes for alcohol-metabolizing enzymes alcohol dehydrogenase and aldehyde dehydrogenase. This affects their response to alcohol and is associated with _________ risk for alcohol use disorder

alcohol, 12, larger, desire, craving, tolerance, withdrawal

Alcohol Use Disorder: DSM V Criteria

-A problematic pattern of _______ use leading to clinically significant impairment or distress, as manifested by at least 2+ of the following, occurring within a __-month period:

• (1) Alcohol is often taken in ______ amounts or over a longer period than was intended

• (2) There is a persistent ______ or unsuccessful efforts to cut down or control alcohol use

• (3) A great deal of time is pent in activities necessary to obtain alcohol, use alcohol, or recover from its effects

• (4) _______, or a strong desire to urge or to use alcohol

• (5) Recurrent alcohol use resulting in a failure to fulfill major obligations at work, school, or home

• (6) Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol

• (7) Important social, occupational, or recreational activities are given up or reduced because of alcohol use

• (8) Recurrent alcohol use in situations in which it is physically hazardous

• (9) Alcohol use is continued despite having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol

• (10) __________

• (11) ___________

intoxicated, depression, coma

Alcohol Intoxication

-Large majority of people who use alcohol have been __________ to some degree

-Occurs as episodes lasting minutes to hours

-Common for patients to require care in the ED

-Overdose Symptoms → respiratory __________, stupor, seizure, shock, ____, and death

recent, behavioral, slurred, nystagmus, coma

Alcohol Intoxication: DSM V

-______ ingestion of alcohol

-Clinically significant problematic __________ or psychological changes that developed during, or shortly after, alcohol ingestion

-One or more of the following symptoms developing during, or shortly after, alcohol use: 

• _______ speech, incoordination, unsteady gait, ________, impairment in attention or memory, and stupor or ____

mild, delirium, DT

Alcohol Withdrawal: Background

-Acute withdrawal syndrome is often unexpected

-Symptoms are usually _____

-Common among medical and surgical inpatients and in ED

-Suspect alcohol withdrawal in unexplained ________

-If identified early, __ mortality rate < 5%

cessation, after, tremor, anxiety

Alcohol Withdrawal: DSM V

-_________ of (or reduction in) alcohol use that has been heavy and prolonged

-Two or more of the following, developing within several hours to a few days _____ the cessation of/reduction in alcohol use:

• (1) Autonomic hyperactivity

• (2) Increased hand ______

• (3) N/V

• (4) Transient visual, tactile, or auditory hallucinations or illusions

• (5) Psychomotor agitation

• (6) _______

• (7) Generalized tonic-clonic seizures

6-36, tremor, nausea, 6-96, hypertension

Alcohol Withdrawal Syndrome: Mild and Severe

-Mild Withdrawal → begins within _-__ hours after last drink

• Symptoms include ______, anxiety, minor agitation, diaphoresis, palpitations, headache, tachycardia, ______/vomiting, and insomnia 

• Symptoms usually pass by 24-48 hours

-Severe Withdrawal → occurs _-__ hours after last drink

• Usually preceded by prolonged heavy alcohol use

• Symptoms include disorientation, agitation, diaphoresis, whole body tremor, N/V, _____________, and hallucinations 

6-48, withdrawal, tonic-clonic, focal, severe, 48-96, hallucinations, death

Alcohol Withdrawal Syndrome: Seizures

-Withdrawal Seizures

• _-__ hours after last drink

• More prevalent in patients with history of __________ syndromes

• Generalized _____-______ seizures that are brief and resolve spontaneously

• Can recur in untreated patients

• Consider other etiology if seizures are _____, prolonged or recurrent, associated with trauma/fever, onset > 48 hours after the last drink

-Delirium Tremens (DTs)

• The most ______ form of alcohol withdrawal

• Acute organic psychosis (typically __-__ hours)

• Symptoms → ___________, disorientation, tachycardia, hypertension, hyperthermia, agitation, and diaphoresis

• Complications → dehydration, electrolyte disturbances, arrhythmias, seizures, CV collapse, and _____

12-24, resolve, visual, aware, not

Alcoholic (Organic) Hallucinosis

-Hallucinations that develop within __-__ hours of abstinence

-Typically _______ within 24-48 hours

-Hallucinations are usually ______; patients are _____ they are hallucinating

-___ associated with global clouding of the sensorium

-Vital signs are usually normal

thiamine, ataxia, nystagmus, amnesia

Chronic Alcohol Syndromes

-Wernicke Encephalopathy

• Acute neuropsychiatric emergency due to _______ deficiency

• Triad = mental status changes, _______, and ocular motor dysfunction (_______, lateral rectus palsy)

• +/- peripheral neuropathy 

• Treatment is IV thiamine

-Korsakoff Syndrome 

• Late manifestation of Wernicke encephalopathy 

• Anterograde and retrograde ________

• + confabulations

• Patients rarely recover

preventable, increased, single-item, 14, 7, all, known

Screening

-Unhealthy alcohol (and drug) use is among the most common causes of ________ death

• Unhealthy = _________ likelihood of health consequence

-Many screening tools available to detect unhealthy alcohol use

• Recommendation is to utilize ______-____ screening

-At Risk Use

• Men > __ drinks/week on average

• Women > _ drinks/week on average

-USPSTF recommends ___ adults be screened to identify unhealthy alcohol use

• Patients with unhealthy use are to receive a “brief counseling intervention”

-Screening is insufficient for someone already _____ to have unhealthy use

AUDIT-C, SASQ, CAGE

Screening Tools and Recommendations

-The NIAAA recommends use of one of the following brief screening tools: _____-_ or ____

-Do not use yes/no questions, leading questions, and ____ questionnaire

TWEAK

What is the screening test for risk of drinking during pregnancy?

negative, 1, 2, abstain, AUDIT

Management

-When patients screen ________, encourage patient to stay within healthy alcohol consumption guidelines

• <_ drink/day in women, <_ drinks/day in men

• Less is more

• Be aware of other medical conditions that would warrant a patient to ______ from alcohol entirely

-When patients screen positive, you need to get more information

• Recommendation is to obtain an _____ questionnaire

AST, ALT, GGT, abstinence, health, Naltrexone

Primary Care Setting: Diagnostic Evaluation and Management

-Diagnostic Evaluation

• Blood alcohol concentration (BAC)

• Liver enzymes → ___, ___, albumin, bilirubin

• CBC

• ___

• Urine drug screen

-Management

• Early recognition with a goal towards ___________

• Preventative ______ and harm reduction measures 

• Psychosocial intervention

• Pharmacologic therapy → Disulfiram, _________, Acamprosate 

observation, chemistry, aggressive, Thiamine, coma

Alcohol Intoxication: Emergent Evaluation and Management

-Mild, isolated intoxication

• Blood alcohol concentration

• __________

-Moderate Intoxication

• BAC and observation

• ________ studies

• Glucose monitoring

• Electrolyte monitoring

-Severe Intoxication

• Moderate management

• _________ supportive care

• Monitor respiratory status → Intubation

• _______ IV

• Admission → ____, significant complications of intoxication, poison control center consult

80, hemoglobin, >, seizure, CIWA

Alcohol Withdrawal: Emergent Evaluation

-BAC

• Legal limit is __ mg/dL

• 100-150 can cause ataxia, dysarthria, nausea, vomiting

• 300+ can be lethal

-Liver enzymes → AST, ALT, albumin, bilirubin

-CBC → _____________

-GGT, UDS, complete metabolic panel, amylase, lipase

-EKG

• Pts _ 50 years

• Cardiac history 

-CT head

• ________ or altered mental status (if not typical for patient) 

• Rule out contributing/alternative pathology

-_____-Ar

15, thiamine, 10, librium, >, admission, Benzodiazepines, Propofol

Alcohol Withdrawal: Management

-CIWA scores < __

• All patients get daily multivitamin with _______ + folate

• Provide explicit plans for follow-up care prior to discharge

-Very mild withdrawal; CIWA-Ar < __

• Gabapentin (DOC) or Carbamazepine

-Mild withdrawal; CIWA-Ar 10-15

• Chlordiazepoxide (______) is the DOC, Diazepam is the alternative

-Severe withdrawal; CIWA-Ar > 15, requires ___________

• Supportive care → IV fluids, thiamine, magnesium multivitamins

• ______________ → first line therapy for all alcohol withdrawal syndromes

• If those fail, try Phenobarbital

• If that fails, the patient needs to get sedated with ________ and intubated