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==Clinical pearls== | ==Clinical pearls== | ||
On evaluation, it's important to distinguish between a "hangover" and withdrawal, since management is very different. | On evaluation, it's important to distinguish between a "hangover" and withdrawal, since management is very different. | ||
| + | Alcohol dependence is a chronic relapsing disorder with suicide rates >10%. | ||
==Further Reading== | ==Further Reading== | ||
Revision as of 20:42, 9 September 2012
Contents
Introduction and Terms
- Blackout refers to a period of anterograde amnesia resulting from being intoxicated, while remaining awake. Alcohol-induced persisting amnestic disorder is known as Wernicke-Korsakoff syndrome.
- Psychological dependence refers to seeking pleasurable experience as the cause of increased drinking.
- Physiological dependence refers to developing a withdrawal syndrome with abstinence from alcohol.
Physiology
Metabolism
Small amount is broken down in the stomach (particularly in men), most metabolized by alcohol dehydrogenase (rate-limiting step) to acetaldehyde. At higher blood-levels, some alcohol is metabolized by CYP450 system. Acetaldehyde is broken down further by ALDH; variation in ALDH lower risk of abuse in Asians, since acetaldehyde produces increased heart rate, nausea, and vomiting.
Neurochemical effects
- acute alcohol intoxication increase dopamine and its metabolites.
- GABA-a receptor is affected to produce sedation, anti-convulsive effect, and muscle relaxation.
- dampening of NMDA receptors during acute intoxication.
Alcohol intoxication effect on Sleep
- Decreased REM sleep
- Decreased stage 4 sleep
- Increased sleep fragmentation
Multiple other effects contribute to vitamin deficiency, peripheral neuropathy, cirrhosis and pancreatitis, WBC, platelet suppression, fetal alcohol syndrome, increased risk for GI, liver, and breast cancer, and cardiomyopathy. Red blood cells increase in MCV.
Genetics and Epidemiology
Alcoholism has a very strong genetic component, as supported by several lines of evidence:
- Children of alcoholic parents, adopted at young age by non-alcoholic families, have 4-fold increase in risk for alcoholism
- Close family members have 4-fold increased risk
- Identical twin risk > fraternal twin risk (K&S)
Lifetime prevalence of alcohol dependence is 10-15% in men and 3-5% in women.
Alcohol use in adolescents
According to large epidemiological study 35% of adolescents (12-17) had used alcohol in the last year; 16% of those who had used alcohol met criteria for an alcohol use disorder (abuse or dependence). Thus the prevalence of alcohol use disorders in adolescents is around 5%. By comparison, of the 13% of adolescents smoked marijuana, a quarter went to develop a drug use disorder. The prevalence of marijuana use disorder and analgesic opioids use disorders were (3.4%) and (1.2%) respectively. (1)
Diagnosis according to DSM-IV-TR
- The diagnostic criteria for abuse focus on impairment in social, legal, and occupational functioning in a patient who is not alcohol dependent.
- It is possible for a patient to meet some criteria for alcohol dependence without alcohol abuse; these diagnostic "orphans" are not adequately accoundted for by the DSM IV.
- Alcohol intoxication is based on evidence of recent ingestion of alcohol with some impairment and at least one physiological manifestation of intoxication.
Managing acute intoxication
Chronic management
Diagnostic pearls
Etiological subtypes (based on Cloninger’s Alcoholism Typology)
- Type 1 (also type A) alcoholism (75%) is characterized by adult onset and drinking to relieve depression and anxiety; alcoholics often feel guilty about drinking. Patients quickly develop behavioral tolerance
- Type 2 (also type B) alcoholism (25%) is characteized by early onset and antisocial and risk-taking behavior while intoxicated; it has been termed male-limited alcoholism due to perceived transmission from fathers to sons
Laboratory tests
- Markers of heay use: GGT (same as GGTP) gamma-glutamyl transferase (or transpeptidase) and CDT (carbohydrate-deficient transferrin). GGT is also elevated in DM, HTN, chronic liver disease (low specificty)
- Elevated AST and ALT with classic ratio of 2:1
- Elevated MCV, a finding also seen in macrocytic and Folate/Vitamin B12 anemias
- Blood alcohol level (BAL)
Clinical pearls
On evaluation, it's important to distinguish between a "hangover" and withdrawal, since management is very different. Alcohol dependence is a chronic relapsing disorder with suicide rates >10%.
Further Reading
(1) Wu et.al. Racial/Ethnic Variations in Substance-Related Disorders Among Adolescents in the United States. Arch Gen Psychiatry. 2011;68(11):1176-1185