Substance Use Disorder

F10 ALCOHOL
Question-Answers from Past Papers

Group C
MBBS 5th Year, 8th Batch
NAIHS
Past Questions: Criteria for ADS
• How would you recognize a case of alcohol dependence syndrome?
Briefly outline the management of this problem. 4+4=8 (2076/02)
• Describe the diagnostic criteria for alcohol dependence syndrome and
its management. 4+4=8 (2075/9)
• Short note on: Criteria for alcohol dependence syndrome. 4 (2073/8)
• Enumerate the criteria for alcohol dependence syndrome. 2 (2065)
• Describe the criteria for alcohol dependence syndrome. How do you
treat a case of alcohol dependence syndrome. 2+2=4 (2064)
Criteria for dependence (ICD-10)
• At least three of the following, has been experienced or exhibited at some
time during last year:
• A strong desire or sense of compulsion to take the substance
• Diffulties in controlling substance-taking behavior in terms of its onset,
termination or levels of use
• Physiological withdrawal state when substance has ceased or been reduced
• Evidence of tolerance, such that increased doses of the psychoactive substance
are required to achieve effects originally produced by lower doses
• Progressive neglect of alternative pleasure or interests because of psychoactive
substance use and increased amount of time to obtain or take the substance or to
recover from its effect
• Persisting with substance use despite clear evidence of overtly harmful
consequences (physical or mental)
Alcohol Intoxication
• A transient condition following administration of alcohol resulting in
disturbances of level of consiciousness, cognition, perception, affect or
behavior, or other psychophysiological function or behaviors.
• Correlates with blood alcohol concentration
BAC Likely impairement
20-30 mg/dL Slowed motor performance, decreased thinking ability
30-80 mg/dL Increase in motor and cognitive problems
80-200 mg/dL Increase in incoordination and judgement errors; mood lability; deterioration in
cognition
200-300 mg/dL Nystagmus, marked slurring of speech, alcoholic blackouts
>300 mg/dL Impaired vitals signs and possible death
 Physical and neuropsychiatric effects of alcohol abuse
Physical effects of excessive use of alcohol Neuropsychiatric effects of excessive use of alcohol

Gastrointestinal Acid peptic disease, fatty liver, alcoholic hepatitis, cirrhosis,

esophageal varices, pancreatitis, carcinoma
Malnutrition Due to poor intake and malabsorption, deficiencies of
Vitamins B1 (thiamine), A, D, B6, E, folate
Neurological Peripheral neuropathy, dementia, cerebellar degeneration,
epilepsy
CVS Hypertension, cerebrovascular accidents, dilated
cardiomyopathy, beri-beri induced high output cardiac
failure, (modest amount – ? reduce CAD)
MSK Myopathy, weakness, osteoporosis, osteomalacia, gout
Effects on fetus Fetal alcohol syndrome: facial abnormality, growth
retardation, muscular incoordination, low intelligence,
hyperactivity
 Wernicke’s encephalopathy
• Acute-onset degenerative encephalopathy
due to thiamine deficiency
• Causes: poor intake, reduced absorption,
decreased hepatic storage, impaired usage • Treatment
• Hospitalization
• Pathology: hemorrhages and secondary gliosis
• High dose parenteral
in periventricular and periaqueductal gray
thiamine for 3-7 days
matter (500mg IV/IM, 3x/day)
• Tetrad of acute confusion, ophthalmoplegia, • Treatment of withdrawal
nystagmus, ataxia • Continue oral thiamine
100mg daily for at least a
month
 Korsakoff’s syndrome
• 80% of people who have Wernicke’s • Treatment
encephalopathy à Korsakoff’s syndrome • Thiamine supplementation
• Amnesia: anterograde, retrograde +
• Absteinence from alcohol
• Confabulation: fabricated memories to • Psychiatric and psychological
fill in lapses of memory therapy
• Personality changes: apathy, • Memory strengthening exercises
indifference, decrease in executive and aids
function • Use of signs and arrows
• Acetylcholinesterase inhibitors
• Disorentation to time, place and person (Donepezil): improve cognitive
• Hallucinations functioning
The alcohol withdrawal syndrome
Time Withdrawal Symptoms
6-12 hours Insomnia, tremulousness, mild anxiety, GI upset, headache, diaphoresis, palpitations,
anorexia
12-24 hours Alcoholic hallucinosis: visual, auditory or tactile hallucinations with intact orientation
24-48 hours Withdrawal seizures: generalized tonic-clonic seizures
48-72 hours Delirium tremens/ Alcohol withdrawal delirium: hallucinations (predom visual),
disorientation, tachycardia, hypertension, low grade fever, agitation, diaphoresis
 Delirium tremens
• A medical emergency, severe form of withdrawal syndrome characterized by:
• Delirium: clouding of consciousness, disorientation in time and place, impairment of recent
memory, illusions, hallucinations, fearfulness, agitation
• Tremulousness, ataxia, autonomic disturbances (sweating, tachycardia, raised BP,
mydriasis), marked insomnia
• Hallucinations: characteristically visual, often frightening, involving Lilliputian people or
animals
• Dehydrattion and electrolyte disturbances
• Begins on the 3rd day
• Lasts for 3-4 days
Management of ADS
• Investigations
• Hospitalization
• Assisted withdrawal
• Prevention of relapse and treatment of underlying problems
• Psychological treatments
• Pharmacological treatments
• Investigations
• CBC, TLC, DLC, Hb
• MCV: raised
• Carbohydrate-deficient transferrin: raised, highly specific
• Blood alcohol concentration
• LFT: GGT raised
• USG Abdomen
• CT Head
• Hospitalization
• Severe dependance
• Previous withdrawal seizures
• Delirium tremens
• Detoxification
• No social support
• Other psychiatric illness or physical illness
• Assisted withdrawal
• Long-acting benzodiazepines
• Acts on GABAA receptors on similar site as alcohol
• Decreased risk of seizures, delirium tremens
• Decreased cravings, tremors, anxiety, insomnia, nausea
• Drug of choice: Chlordiazepoxide [long T1/2 (100 hours), less likely to be abused]
• Day 1: 20mg, 4x/day
• Day 2: 15mg, 4x/day
• Day 3: 10mg, 4x/day Fixed-dose chlordiazepoxide treatment regimen
• Day 4: 5mg, 4x/day
• Day 5: 5mg, 2x/day
• Lorazepam 2-10mg/day; Diazepam 5-20mg/day (decrease 20% on subsequent days, complete
tapering off in 4-5 days)
• B-vitamins
• Parenteral 100mg thiamine twice daily for 3-5 days
• Followed by oral thiamine for 6 months
• Hydration: 5% dextrose (only after thiamine)
• B-blocker: Propranolol 20-80mg in divided doses
Prevention of relapse and treatment of underlying problems

• Psychological treatments
• Cognitive behavioral therapy
• Brief intervention
• Motivational interviewing
• Individual and group therapy
• Day patient or rehabiliation program
• 12-step program (Alcoholic anonymous)
• Family therapy
• Pharmacological treatment
• Deterrent agents
• Anticraving agents
• Others: vitamin supplementations, antidepressants (and other
medications) for psychiatric comorbidities
• Deterrant agents - alcohol sensitising agents
• Disulfiran (Antabuse, 125-500 mg/day for 6 months)
• Inhibits aldehyde dehyrogenase à accumulation of aldehyde à unpleasurable effects
(flushing, headache, nausea, vomiting, palpitation, shortness of breath)
• Started at least after 12 hours of last ingestion of alcohol
• Side effects: persistent metallic taste, GI upset, peripheral neuropathy, suicidal ideation
• Citrated calcium carbimide (CCC)
• Metronidazole
• Animal charcoal, sulfonylureas,..
• Anticraving agents
• Acamprosate 666mg 3x/day
• Enhances GABA transmission in CNS
• Started 2-7 days after cessation, upto 6-12 months
• Naltrexone 50 mg/day
• Inhibit release of endogenous endorphins on alcohol consumption
Disulfiram

Disulfiram – Pharmacological Profile

Action Inhibits intermediate metabolism of alcohol, causing build-up of acetaldehyde and
reactions of flushing, sweating, nausea, tachycardia, if patients drink alcohol
Contraindications Concomitant use of alchol, alcohol containing preparations, metronidazole,
coronary artery disease, severe myocardial disease
Precautions High impulsivity (likely to drink), psychoses, DM, epilepsy, hepatic dysfunction,
hypothyroidism, renal impairement
ADR Metallic aftertaste, dermatitis, hepatitis, optic neuritis, peripheral neuropathy,
psychotic reactions, pregnancy category C
Drug Interactions Amytriptyline, warfarin, diazepam, phenytoin, theophylline
Usual adult dose 250mg/day (125-500mg)
At least 12 hours after drinking, otherwise disulfiram-alcohol reactions, may last
upto 2 weeks of last dose
Follow-up: monitor LFT periodically