ALCOHOL BASICS PROF.DR .ELANGOVAN’S UNIT

D.SUBBURAJ

EPIDEMIOLOGY

• MC substance abuse in INDIA -ALCOHOL– NEXT MC- CANNABIS

• South india prevalance -33—55%• Highest alcohol consumption -- KERALA

– 8 L / CAPITA• WORLD WIDE—LUXEMBOURG (15.5 L)

ALCOHOL

1 unit=10gm=12.5 ml absolute alcohol=1 drink• Can’t be stored in the body• Energy -7 kcal gm• Some amount of other nutrients

– some potassium ; no sodium– Riboflavin & niacin– Possible antioxidant benefits from

polyphenols(?)– sometimes VIT C

STANDARD DRINK

• any drink that contains about 14gmOf absolute alcohol

AUSTRIA 6 gm

U k 8 gm

AUSTRLIA 10 gm

FINLAND 11 gm

CANADA 13.6 gm

U S 14 gm

JAPAN 19.75 gm

STANDARD DRINK

Beer 4 – 8 %

Vodkas 40.0 - 50.0 Wines 7– 22 %Gin 40.0 - 48.5

Rum 40.0 - 95.0 Whiskies 40.0 - 75.0 Brandies 40.0 - 43.0

BINGE DRINK

• U S DEFINITION– Consumption of five or more standard drink by

males , four or more by females in about 2 hrs• U K DEFINITION

– Drinking more than twice the daily limit (>8 men, >6 women)

• NIAAA DEFINITION– Any time one reaches a peak BAC of 0.08% or

higher

SAFE DRINK

• no uniform guidelines• UK– 2-3 standard drink daily or 14 per week• USA– 1 standard drink daily or 7 per week• Not more than 3 drinks on any one occasion• Don’t drive or engage in hazardous activities• Don’t drink if an interacting drug has been

taken

Where does Alcohol come from?

Grain whisky and beer

Sugar rum

Honey mead

Apples cider

Grapes wine and brandy

Potatoes vodka

COCK TAIL DRINK K J1 glass stout (250 ml) 570

1 glass beer (250 ml) 380

1 Glass white wine (100 ml) 280

1 Glass red wine (280 ml) 280

1 Nip of spirit 40% (30 ml ) 250

1 Glass mixer (440 ml) 440

1 Glass diet mixer (250 ml) 5

13

14

Graph source: National Institue on Alcohol Abuse and Alcoholism

Factors that influence absorption

• Gender– Women produce less of enzyme needed to breakdown

alcohol– Women have greater fat content and alcohol is not fat

soluble so it enters the blood stream faster– Women have less water so alcohol does not become

diluted– Women absorb more alcohol during the premenstrual

phase

• Absorption increased by – Rapid gastric emptying ( carbonated beverages)– Absence of meal– Absence of congener– Dilution

• Tissue distribution - blood flow & water content

• Obese persons & women- higher BAC• Follows zero – order kinetics • So metabolism doesn’t vary widely in the

population

MEOS- microsomal ethanol oxidizing system -CYP2E1

3-pathways of EtOH metabolism

ADH in stomach (males) ADH & MEOS in liver (males &

females)

Catalase in liver (males & females)

ETHANOL

CATALASE ADH MEOS

ACETALDEHYDE

ALDH MITOCHONDRIA ACETATE

EXTRA HEPATIC TISSUES

Microsomal Ethanol Oxidizing System (MEOS)

• Alternate pathway used, in addition to ADH, when alcohol intake is excessive

• End products include:– Ethanol acetaldehyde– NADPH + H+ NADP+

No ATP formation = Energy Wasteful• Also involved in drug metabolism

– Excess ethanol- less MEOS for drug- drug overdosage

Genetic Variation

•50% of Asians have inactive ALDH•Develop flushing reaction•Acetaldehyde Dehydrogenase (ALDH) varies in Caucasians, Blacks and Asians.• poly morphism TNF PROMOTER - susceptible to alcoholic steatohepatitis•Alcoholism -inherited ; specific gene not identified

Metabolic effects

• High NADH/NAD RATIO– Prevents pyruvate entering in to

gluconeogenesis- HYPOGLYCEMIA– Converts pyruvate to lactate - acidosis-

uricacidaemia- GOUT– Increase TG - FATTY LIVER

• INDUCES DRUG METABOLISM• FREE RADICAL FORMATION• ACCUMALATION OF ACETALDEHYDE

POSSIBLE HEPATO TOXIC EFFECTS OF ACETALDEHYDE

• Increase lipid peroxidation • Binds plasma membrane• Interferes with mitochondrial electron

transport chain • Inhibits nuclear repair• Interferes with microtubule formation• Activates complement• Increases collagen synthesis

DRUG INTERACTIONS

• Synergies with anxiolytics, antidepressants, antihistamines, hypnotics, opioids-- marked CNS depression with motor impairment -- chances of accidents increase

• Insulin & sulfonylureas: enhances hypoglycaemia• Aspirin & other NSAID –gastric bleeding• Parcetamol toxicity• Acute alcohol ingestion inhibits , chronic

alcoholism enhances phenytoin metabolism

Disulfiram like reaction• irreversible ALDH inhibitor- acetaldehyde

accumulates flushing reaction

DIAGNOSIS OF ALCOLISM

• TOLERANCE– A state of adaptation in which increasing amounts of

alcohol are needed to produce desired effects• PHYSICAL DEPENDENCE

– A typical withdrawal syn appears on interruption of drinking , which is relieved by alcohol itself or other drugs

• IMPAIRED CONTROL– Total alcohol intake cannot invariably be regulated , once

drinking has begun at any drinking occasion• CRAVING

– A dysphoria of abstinence that leads to relapse

Causes of Alcoholism

• Genetics– Strong family link– 50% of fathers, sons, brothers of alcoholics are likely to

become alcoholics– Children of alcoholics are more then 3-4 times more likely

to become alcoholics

• Personality types– Low self esteem– Chronic anxiety– Antisocial personalities

QUESTONNAIRES

• CAGE ( cut down , annoyed ,guilty, eye-opener)

• MAST (michigan alcoholism screening test)• AUDIT ( alcohol use disorder identification

test)• RAPS4 (rapid alcohol problems screen 4)• QFS ( quantity frequency score)

CAGE QUESTIONARE

• Have you ever felt to cut down?• Have people annoyed you by criticizing ?• Have you ever felt guilty or bad ?• Have you ever had a drink first thing in the

morning to steady your nerves or to get ride of hang over? (eye opener)

One ‘yes’ – suspicion More than one-alcohol abuse or dependance

CLINICAL COURSE

• Age at first drink 13—15 yrs

• Age at first intoxication 15—17 yrs• Age at first problem 16—22 yrs• Age at onset of dependence 23---40 yrs• Age at death 60 yrs

• Spontaneous remission in 20% Same as general population.

DSM-IV CRITERIAS

• ALCOHOL ABUSE• Recurrent use of alcohol associated with any

one of the following with in 12mns1. Failure to fulfill major role at work2. Physically hazardous3. Related legal problems4. Despite of having persistent social problems

ALCOHOL DEPENDENCE

• Any one of following in 12 mns• Increased amount of alcohol needed to achieve

desired effect & continued use of same amount• Withdrawal symptoms• Persistent desire to cut down• Important social /recreational activities given up• Increased time spent to obtain/to use /to recover

from the effects alcohol

Collection of blood for alcohol

• Spirit - not used to clean skin • Preservative –sod fluoride(100mg)+potassium

oxalate(30 mg)• Refrigerated, should not be freezed• WIDMARK FORMULA

– Wt of alcohol(gm) in body= BWT X BAC X 0.6 (men) 0.5(women)

Breath analysis

• Alcohol absorbs infra red rays• Amount of infra red rays absorbed is

proportional to alcohol contents• 60—100ml of air is receieved in a plastic

balloon • End portion of forced expiration gives correct

results• Conc in exhaled air is about 0.05% of blood

content

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