SEMINAR ON SUBSTANCE ABUSE -ALCOHOL

I. INTRODUCTION Alcohol is a natural substance formed by the reaction of fermenting

sugar with yeast spores. Alcohol beverage known scientifically as ethyl alcohol and chemically

as C-2H-5OH and its abbreviation is EtOH.

Alcohol is classified as a food as it contain calories but has no nutritional value. American beer contain 3-6% alcohol, wine-10 -20% and distilled beverage contain 40 -50% alcohol.

Its create a pleasurable experience that encourage the drinker to repeat it ; and abuse it.

The Diagnostic and Statistical Manual of Mental Disorder (DSM-iv) seperates substance abuse disorder into to categories. Substance –use disorder such as abuse and dependence and substance- induced disorder such as intoxication and withdrawal.

II. DEFINITION

• Alcoholism dependence syndrome or Alcoholism refers to the use of alcohol beverages to the point of causing damage to the individual, society or both.

III. EPIDEMIOLOGY OF ALCOHOL ABUSE

• About half of American 12 years of age and older are current drinker, of the these about ¼ are binge drinkers or engage in heave alcohol use.

• The incidence of alcohol dependence is 2% in India. While 20 -40% of subjected aged above 15 yrs are

current user. Nearly 10 % of them are regular or excessive user. Nearly , 15 -30 % of patient are developing alcohol –

related problems and seeking admission in psychiatric hospital.

III. ETIOLOGY OF ALCOHOL ABUSE

1. Biological factors :i. Genetic vulnerability.ii. Co-morbid psychiatric disorder / personality disorder.iii. Co-morbid medical disorders.iv. Re-enforcing effect of drugs.v. Withdrawal effect and craving of drug use.vi. Biochemical factor (role of dopamine, nor

epinephrine in cocaine , ethanol and alcohol dependence).

2.Pyschological factor:

i. Curiosity.ii. General rebelliousness and social non-confirmity.iii. Early initiation of alcohol and tobacco.iv. Poor impulse control.v. Sensation seeking .vi. Loss self esteem .vii. Concern regarding personal autonomy.viii. Poor stress management skill.ix. Childhood trauma or loss.x. Relief from fatigue or boredom.xi. Escape from reality.xii. Lack of interest in conventional goals.xiii. Psychological distress.

3 .SOCIAL FACTOR :

i. Peer pressure.ii. Modeling.iii. Ease of availability of alcohol.iv. Strictness of drug law enforcement.v. Intra-familial conflict.vi. Religious reasons.vii. Poor social/ familial support.viii.Perceived distance within the family.ix. Permissive social attitude .x. Rapid urbanisation

V. PROPERTIES OF ALCOHOL Alcohol is a clear colored liquid with a strong burning

taste. The rate of absorption of alcohol in the blood stream is

rapid than its elimination. Absorption of alcohol into the blood stream is slower

with food in the stomach. A small amount is excreted via urine and exhle. Alcohol level of : 80 -100% in 100ml blood – Intoxication. 200 -250 mg- toxic, sleepy, confused and altered

thought. 300%/100ml -Loss of consciousness. 500%/100ml - Fatal.

VI. PHASES OF ALCOHOL ABUSE

Jellinek (1952) outlined phases of alcohol abuse

Phase I The Pre- Alcoholic Phase: The use of alcohol to relieve the

everyday stress and tension life. Tolerance develops and the

amount required to achieve the desired effect increase steadily.

Phase II The Early Alcoholic Phase This phase begin with blackout –

brief period of amnesia that occur during or immediately following a period of drinking.

Alcohol is no longer a source of pleasure or relief but rather a drug that is required by individual.

Feeling of guilt and defensive about drinking is seen.

Phase III The Crucial PeriodThe individual has loss control and

physiological dependence and inability to choose whether or not to drink.

In this phase individual is extremely sick.

Drinking is the main focus and is willing to risk everything that was once important.

Phase Iv The Chronic phase

It is characterized by emotional and physical disintegration.

The individual is usually intoxicated more often then sober.

Life threatening physical manifestation may be evident.

Abstinent from alcohol result in various terrifying syndrome.

VII. CLASSIFICATION OF ALCOHOLISnFACTOR

Synonym Milieu limited Male limited

Gender Both sexes Mostly in male

Age of onset >25yrs <25 yrs

Etiological factor Genetic factor important & strong environmental influence

Heritable, environmental influence limited.

Family history May be positive Parental alcoholism and anti-social behavior usually present.

Loss control Present No loss f control.

Other features Psychological dependence and guilt present

Drinking followed by aggressive behavior, spontaneous alcohol seeking

Pre-morbid personality Harm avoidance, high reward dependence.

Novelty seeking.

VIII PATTERN OF ALCOHOL USEA. ALPHA (A)i. Excessive and inappropriate drinking to relieve physical and

or emotional pain.ii. No loss of control.iii. Ability to abstain alcohol present.

B. BETA (B)iv. Excessive and inappropriate drinking.v. Physical complication due to cultural drinking pattern and

poor nutrition.vi. No dependence.

(Contd)

C. GAMMA (Y)i. It I also called malignant alcoholism.ii. Progressive course.iii. Physical dependence with tolerance and withdrawal symptoms.iv. Psychological dependence with inability to control drinking.

D. DELTA v. Inability to abstain.vi. Tolerance.vii. Withdrawal symptom.viii. The amonut of alcohol consumed can be controlled.ix. Social disruption is minimal. E. EPSILON (E)x. Disomania ( compulsive drinking).xi. Spree-drinking.

IX SIGN AND SYMPTOM OF ALCOHOLISM

Minor complaint: malaise, dyspepsia, mood swing or depression, increased incidence of infection.

Poor personal hygiene, untreated injuries. Unusual high tolerance for sedative and opiod. Nutritional deficiencies. Sedative behavior. Consumption of alcohol containing product. Denial of problems. Tendency of blaming others and rationalize problems.

ICD 10 CRITERIA FOR ALCOHOL DEPENDENCE

A strong desire to take the substance. Difficulty in controlling substance taking

behavior. A physiological withdrawal state. Development of tolerance. Progressive neglect of alternative pleasure of

interest. Persisting with substance use despite clear

evidence of harmful consequences.

X. TYPES OF INTOXICATION OF ALCOHOL

1. ACUTE INTOXICATION After a brief period of excitation, there is generalized

central nervous system depression with alcohol use. With increasing intoxication, there is increases reaction

time, slow thinking, distractibility and poor motor control, later dysarthria, ataxia and in coordination can occur with progressive loss of self control and frank disinhibited behavior.

Intoxication sign are seen in blood alcohol level of 150 –200mg%, at 300 -450gm% increasing drowsiness followed by coma. Blood alcohol level of 400 – 800gm% is fatal.

A small dose of alcohol causing intoxication is known as ‘pathological intoxication’.

‘

2. WITHDRAWL SYNDROME The withdrawal symptom most commonly seen is a hang over on the

next morning. Mild nausea, vomiting, weakness, irritability, insomnia and anxiety are common withdrawal symptom. Some severe symptoms are –

a. Delirium tremors (DT) :• It is most severe withdrawal symptom and death occur in 5 – 10%.• It occurs usually in 2- 4 days of complete abstinence of alcohol.• The course is short with recovery within 3-7 days.• This is organic brain syndrome, characteristic feature are- - Clouding of consciousness. -Poor attention span and distractibility. -Visual and auditory hallucination. -Marked autonomic disturbance. -Psychomotor agitation and ataxia. - Insomnia - Dehydration and electrolyte imbalance.

b. Alcoholic Seizures (Rum Fit )• It is generalized tonic clonic seizure occur in 10%

alcohol dependence, usually after 12- 24 hours after heavy bout of drinking.

• Multiple seizure ( 2- 6 at one time) are common.• Status epilepticus may be precipitated and 30 % cases ,

delirium tremors follows.c. Alcoholic Hallucinosis • It is characterized by presence of halucintion during

partial or complete abstinence following regular alcohol intake.

• Usually recover after 1 month or rarely more than 6 months.

d. Wernicke’s encephalopathy• This is an acute reaction due to severe deficiencies of thiamine.• Characteristically the onset occurs after period of persistent vomiting.

Its important clinical sign are- -Ocular sign: coarse nystagnes, opthalmoplegia, pupillary

irregularities, retinal hemorrhage, papillo edema, etc. -Higher mental function disturbances. -Peripheral neuropathy and severe malnutrition.

e. Korsakoff’s psychosis• It is identified by syndrome of confusion, loss of recent memory and

confabulation.• It is frequently encountered in client recovering from Wernicke’s

encephalopathy.• In USA, these two disorder are called together as “Wernicke’s-

Korsakoff.

XI. LABORATORY INVESTIGATION

1. GGT ( Gamma Glutryl Transferase

2. MCV ( Mean corpuscular Volume.)

3. Others4. Echo, ECG and X-ray.5. MAST (Michigan

Alcoholism.6. Body Fluid Alcohol

level

BLOOD ALCOHOL LEVEL.BLOOD ALCOHOL CONCENTRATION BEHAVIORAL CORRELATE

25 -100 Excitement.

80 Legal limit for driving in UK .

100 -200 Serious intoxication, slurred speech, incordination nystagmus.

200 – 300 Dangerous.

300 – 350 Hypothermia , dysarthria, cold sweat.

350 – 400 Coma , respiratory depression.

> 400 Death nay occur

XII. CAGE QUESTIONAIRE• CAGE questionnaire is an acronym of its four question, widely used for

screening for alcoholism.• It was developed by John Ewing, founding director Boules Center for alcohol

Studies, University of North Caroline. • CAGE questionnaire are – 1.Have you ever felt you needed to Cut down on your drinking? 2. Have people Annoyed you by criticizing your drinking. 3.Have you ever felt Guilty about drinking. 4. Have you ever needed Eye opener drink( early in he morning)?Scoring- Give 1 for each “yes” answer. A score of 2 or more identifies problems drinkers. Question 1 “yes” – 25% alcoholic. Question 2 “yes” -50% alcohol problems. Question 3 “yes” – 75% alcohol problems. Question 4 “yes” – 95% alcohol problems.

XIII. MANAGEMENT OF ALCOHOL WITHDRAWAL SYNDROME

A. Detoxification: It is the treatment for alcohol withdrawal and drug of choice is ‘benzodiazepine’.

• The most commonly used drug are chlordiazepoxide 80 -200mg and diazepam 40 -80 mg/day in a divided dose.

B. Others -Vitamin B. -Anti convulsant. - Fluid and electrolyte balances. C. Alcohol deterrents therapy These agent are those which are given to desensitize the individual to

the effect of alcohol and maintain abstinence in treatment of alcohol dependence. It main effect is to produce rapid and violently unpleasant reaction in a person who ingest even a small amount of alcohol while taking disulfiram

Disulfiram: It is used to ensure abstinence in treatment of alcohol dependence. It main effect is to produce rapid and violently unpleasant reaction in a person who ingest even a small amount of alcohol while taking disulfiram.

Mechanism of action :• It is an aldehyde dehydrogenase inhibitor that interferes with

metabolism of alcohol and produce a marked increases in blood acetaldehyde level( more than 10 time level) producing wide array of unpleasant reaction called ‘ Disulfiram ethanol reaction’.

• DER is characterized by nausea, throbbing headache, vomiting, hypotension, flushing, sweating, thirst. dyspnea, tachycardia chest pain, vertigo, blurred vision with severe anxiety.

Therapeutic indication: Aversive conditioning treatment for alcohol dependence.

Side effect : Fatigue, dermatitis, impotence, optic neuritis, mental change, acute polyneuropathy and hepatic damage. In extreme casa convulsion, respiratory depression, cardio vascular collapse, myocardial infarction and death.

• Contraindication : -Pulmonary and cardio vascular diseases. -Use cautious in renal, CNS ,hormonal disorder. -Patient at risk of alcohol ingestion.• Dosage: Initial dose is 500mg/day orally for first 2week and

followed by 250mg/day.• Nursing responsibilities: Informed consent. 12 hour should lapse since last ingestion of alcohol before

administering the drug. Instruct and warn patient not to take alcohol and alcohol

containing preparation. Caution patient against taking CNS depressant or OTC. Instruct patient to avoid driving. Warned that DER can last till 2 week after the therapy. Instruct to carry identification card. Emphasize importance of follow up.

d. Psychological treatment

Motivational interviewing Group therapy.Aversive conditioning.Cognitive therapy.Relapse preventive technique.Cue exposure technique.

XIV. TREATMENT OF ALCOHOL ABUSE

1. Detoxification:• The best way to stop alcohol is to stop it suddenly.• The aim of detoxification is symptomatic

management of emergent with drawal symptom.• The drug of choice are- a. Chlordiazepoxide -20mg QID in day 1. -15mg QID in day 2. -10 mg QID in day 3. -5mg QID in day4. -5mg BD in day 5 and none in day 6.

b.Diazepam -40 -80 mg/day in divided dose. c.Clormethiazole - 1-3g/day (for experimenrtal used). d. Clormethiazole - 600 – 1600 mg/day (for experimental used Vitamin b ( 10mg thiamine ) twice every day for 3

-5 days , followed by oral route at least 6 month Care of dehydration ,without giving DW 5%.

2. Behavior therapy.• Aversion therapy using a sub- threshold electric

shock.• Convert sensitization, relaxation technique,

assertiveness technique, assertive training, self control skill and positive reinforcement.

3.Psychotherapy:• It can be both group and individual group therapy.• Education about alcohol and its risk is given.• Motivational enhancement therapy and lifestyle

modification is useful.4. Group therapy:• Alcohol Anonymous.

5. Deterrent agent (Alcohol sensitizing drug): i. Citrated Calcium Carbonate. ii. Metronidazole. iii. Animal charcoal, cephalosporin,etc.6.Anti-craving agent. -Acamprosate ( the ca++ salt of N-acetyl-

homotaurinate) -Naltrexone (oral opiod receptor antagonist) -SSRI’s- fluoxetine.7.Other medication - Anti-depressant, anti- psychotic, narcotis, lithium

etc.

XV. NURSING MANAGEMENT USING NURSING PROCESS

1. Risk for injury related to hallucinosis, acute intoxication secondary to confusion, disorientation, inability to identify potentially harmful situations.

2. Altered health maintenance related to inability to identify, manage or seek out help to maintain health, evidenced by various physical symptom, exhaustion, sleep disturbance.

3. Ineffective denial related to weak, under-developed ego, evidence by lack of insight, blaming others, failure to accept responsibilty for his behavior.

Contd…

4. Ineffective individual coping related to impairment of adaptive behavior and problem solving abilities evidenced by use of substance as coping mechanism.

5. Disturb family process related to alcoholism as evidenced by relationship discord, frequent flight, misunderstanding and confusion.

XVI.AGENCIES CONCERNED WITH ALCOHOL RELATED PROBLEM:

ALCOHOLICS ANONYMOUS (AA):

This is a self-help organization founded in the USA by tow alcoholic men, Dr. Bob Smith and Bill Wilson, a stokbroker on the on the 10th of June in 1935.

The organization works on the firm belief that abstinence must be complete. The only requirement for membership is a desire to stop drinking.

AL ANONStarted in late 1950 by

Mrs Anne, wife of Dr.Bob to support the spouse of alcoholic.

The parent, children, spouse, partner, siblings, family member, friends, employer, employees and co-workers of alcoholic are the members.

AL-ATEEN: AL-teen is a part of AL-Anon family.

It is a family group which provides support to their teenage children

ALCOHOLIC HOSTEL:These are intended mainly

for those rendered homeless due to alcohol related problem.

XVII: COMPLICATION OF CHRONIC ALCOHOL USE:

A. Medical complication:a. Central nervous system-i. Peripheral Neuropathyii. Delirium tremorsiii. Run fitsiv. Alcohol hallucinosisv. Alcoholic jealousyvi. Wernicke Korsakoff psychosisvii. Manchiajava-Bignani diseaseviii. Alcoholic dementiaix. Suicidex. Cerebrellar degeneration

xi. Central pontire myeliniosisxii,. Head injury and fracture.B. Gastro- Intestinal ComplicationHepatic :-fatty liver, cirrhosis of liver, hepatitis Gastric:-gastritis, reflux oesphagitis, peptic ulcer, ca.

stomach and esophagus.Malabsorption syndrome, protein-losing

enteropathy, portal hypertension, ascitis.Pancreatic- pancreatitis, pancreatic cancer.

c. Miscelleneous Acne mosacea, palmar

erythema, rhinophyma, spider naevi, parotid enlargement.

Foetal alcoholic syndromeAlcoholic hypoglycaemia and

ketoacidosisAccidental hypothermiaMalnutrition, pellagra. Leukopenia,

thrombocytopenia.d. Cardiovascular complicatione. Genito –urinary(GU) system

• B. SOCIAL COMPLICATION:• Accidents• Marital disharmony• Divorce• Occupational problem• Increase incidence of drug

dependence• Criminality• Financial difficulties.

XVIII: PROGNOSIS:Every 10 people , who say they will stop drinking, only 4

do.Over 700,000 people per day receive treatment for

alcohol dependence.Approximately 20% achieve long term soberity without

treatment.Approximately 50 – 60 % remain abstinent at the end of

a end of year after treatment.Motivation and intervention by family or friend can help

the alcoholic achieve abstinence.Those with poor, social support, poor motivation or

psychiatric disorder has poor prognosis and tend to relapse within a few years of treatment.

IXX. JOURNAL REVIEW.

GRAPE WINEVS

XX. CONCLUSION Alcohol is the major ingredient in many over the counter and prescription medicine that are prepared in

the concentrated form. Alcohol can be harmless and enjoyable- sometimes if it

is used responsibly and in moderation. Alcohol has the potentiality for abuse.

For alcoholic dependence management the degree of individual involvement and family support is

equivalent. The goal for treatment of alcohol dependence is

abstinence, which need a lot of motivation from patient and family.

t

THANK YOU