1	Alcohol-Related Disorders By Adam J. Frank
2	Substance-Related Disorders Substance abuse is as common as it costly to society. It is etiologic for many medical illnesses and frequently is comorbid with psychiatric illness. The DSM-IV defines substance abuse and dependence independent of the substance. Hence, alcohol abuse and dependence is defined by the same criteria as heroin abuse and dependence.
3	SUBSTANCE ABUSE The DSM-IV defines substance abuse as a maladaptive pattern of substance use leading to clinically significant impairment or distress as manifested by: Recurrent substance use in situations in which it is physically hazardous; Recurrent substance-related legal problems; Failure to fulfill major role obligations at home, school, or work; Recurrent substance use despite persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance.
4	SUBSTANCE DEPENDENCE Substance dependence is defined as a maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by three (or more) of the following:
5	"Tolerance" Tolerance Withdrawal Repeated, unintended, excessive use Persistent efforts to cut down Excessive time spent trying to obtain the substance Reduction in important social, occupational, or recreational activities Continued use despite awareness that the substance is the cause of psychological or physical difficulties
6	Alcohol Intoxication defined by: The presence of slurred speech, incoordination, unsteady gait, nystagmus, impairment in attention or memory, stupor or coma, and clinically significant maladaptive behavioral or psychological changes that develops during or shortly after alcohol ingestion.
7	Differential Dx. Of Alcohol Intoxication The diagnosis of alcohol intoxication must be differentiated from other medical or neurologic states that may mimic intoxication. For example: Diabetic hypoglycemia Toxicity of various agents (ie. Lithium, ethylene glycol, phenytoin) Intoxication with benzodiazepines or barbiturates
8	Confirmation of Diagnosis of Alcohol Intoxication Serum toxicologic screening BAL (blood alcohol level)
9	Alcohol Dependence Alcohol abuse becomes alcohol dependence when TOLERANCE and WITHDRAWAL symptoms develop. The patient drinks larger amounts of alcohol over extended periods of time. The patient will spend a great deal of time attempting to obtain alcohol. The patient may reduce his or her desire to participate in important social, occupational, or recreational activites because of alcohol and its effects.
10	Epidemiology 2/3 of Americans drink occasionally 12% are heavy drinkers (drinking almost everyday and becoming intoxicated several times a week) 14% Lifetime prevalence of alcohol dependence 4:1 Male/Female prevalence ratio
11	Etiology The etiology of alcohol dependence is unknown. Monozygotic twin studies show a partial genetic basis (particularly for men). Male alcoholics are more likely than female alcoholics to have a family histroy of alcoholism.
12	Etiology cont. Compared with control subjects, the relatives of alcoholics are more likely to have higher rates of depression and antisocial personality disorder. Adoption studies also reveal that alcoholism is multidetermined: genetics and family environment both play a role.
13	Clinical Manifestations The alcohol-dependent patient may deny and/or minimize the extent of drinking, making the early diagnosis of alcoholism difficult. The patient may present with accidents or falls, blackouts, motor vehicle accidents, or after an arrest for driving under the influence.
14	Clinical Manifestations cont. Because denial is so prominent in the disorder, collateral information from family members is essential to the diagnosis.
15	Physical findings: (suggestive of alcoholism) Early: acne rosacea, palmar erythema, and painless hepatomegaly Late: cirrhosis, jaundice, ascites, testicular atrophy, gynecomastia, and Duputytren’s contracture.
16	Medical Disorders with increased incidence in alcoholic patients Pneumonia Tuberculosis Cardiomyopathy Hypertension Gastrointestinal Cancers (ie.,oral, esophageal, rectal, colon, pancreas, and liver)
17	Neuropsychiatric complications of Alcoholism Wernicke-Korsakoff syndrome (*Secondary to Thiamine deficiency) Wernicke stage: Nystagmus Ataxia Mental confusion
18	Neuropsychiatric Complications Korsakoff’s psychosis, consisting of anterograde amnesia and confabulation. Alcoholic hallucinosis Alcohol-induced dementia Peripheral neuropathy Substance-induced depression Suicide
19	Management Alcoholic intoxication is treated with supportive measures, including decreasing external stimuli and withdrawing the source of alcohol. Intensive care may be required in cases of excessive alcohol intake complicated by respiratory compromise. All suspected or known alcohol-dependent patients should receive thiamine and folate supplementation.
20	Minor Withdrawal The “shakes” begin 12-18 hours after cessation of drinking and peak at 24-48 hrs. Untreated, uncomplicated alcohol withdrawal lasts 5 to 7 days. Withdrawal is characterized by tremors, nausea, vomiting, tachycardia, and hypertension.
21	Treatment of Minor Withdrawal Chlordiazepoxide (Librium) or Oxazepam (Serax) titrated to the degree of withdrawal signs. The goals of treatment are prevention of more serious complications and patient comfort.
22	Major Withdrawal The risk of alcoholic seizures (“Rum-fits”) begins 7 to 36 hours after cessation of drinking and peaks between 24 and 48 hrs. One to six generalized seizures are common but rarely lead to status epilepticus. Alcoholic seizures precede delirium tremens in 30% of cases.
23	Major Withdrawal cont. Seizures are treated acutely with IV Benzodiazepines. Prophylactic phenytoin (Dilantin) should be administered during the high-risk period in patients with a history of withdrawal seizures.
24	Alcoholic Hallucinosis Onset usually within 48 hours of cessation of drinking and may last more than a week. Characterized by vivid Auditory hallucinations in the presence of a clear sensorium. Treated with neuroleptics (ie. Haloperidol) Rarely these hallucinations may become chronic
25	Delirium Tremens Alcohol withdrawal delrium is a life-threatening condtion manifested by delirium, autonomic hyperarousal, and mild fever. Typically begins 2 to 3 days after abrupt alcohol reduction or cessation. Treated with IV Benzodiazepines and supportive care. Typically lasts for 3 days but may persist for weeks.
26	Alcohol Rehabilitation Two goals of rehabilitation are sobriety and treatment of comorbid psycopathology. In order to have a lasting recovery, the patient must stop denying the illness and accept the diagnosis of alcohol dependence. Group programs “Alcoholic Anonymous” Disulfiram (Antabuse) Naltrexone
27	Overall Outlook Many studies have demonstrated benefits from rehabilitation programs, but nearly half of all treated alcohol-dependent patients will relapse, most commonly in the first six months.
28	"THE" THE END