Alcohol-Related disorder

Substance and Substance Related

Disorders
Substance =

Substance Related Disorders =

Alcohol-Related disorder
Alcohol-Related disorder DSM-IV 2

Substance use disorder

Substance Abuse
Substance Dependence

Substance-induce disorder

intoxication, withdrawal, delirium,

dementia, amnestic disorder, psychotic disorders, mood disorders,
anxiety disorders, sexual dysfunctions, sleep disorder

Substance Use Disorders

Substance Abuse

Substance Dependence

(Addiction)

Alcohol Use Disorder screening

AUDIT(ALCOHOL USE DISORDER

IDENTIFICATION TEST)
WHO

primary care setting

Domains of the AUDIT

Domains
Hazardous Alcohol
Use
Dependence Symptoms

Harmful Alcohol
Use

1
2
3
4

5
6
7
8
9
10

Blackout

AUDIT
AUDIT

Problems

Intervention

0-7

Low risk

Alcohol Education

8-12

Hazardous/Harmful

>13

Dependence

Brief
Advice/Intervention
Diagnostic evaluation
and treatment

Alcohol Use Disorder screening

CAGE

2

Alcohol Use Disorder screening

CAGE
1. Cut down : ,
2. Annoyed :
,
3. Guilty : ,

4. Eye opener : ,

Alcohol Use Disorder intervention

Motvation interview
CBT
Brief intervention
FRAMES

Alcohol Use Disorder intervention

FRAMES
Feedback: Specifically address concerns about use
Concerned about how alcohol is affecting your liver
Responsibility: Emphasize that change is up to patient
Only you can decide to make your life better
Advice: Give specific goals you have for the patient
I want you to be evaluated at a treatment center

Alcohol Use Disorder intervention

FRAMES
Menu: Offer alternatives to advice
You could alternatively go to an AA meeting
Empathy :
I know you find talking about this difficult
Self-efficacy :You deserve better - you can be better with help

Alcohol intoxication

Alcohol intoxication
Metabolism:

liver 90%,
lung + kidney 10 % (unchanged)
Goal

Alcohol intoxication
Blood alcohol
Clinical presentation
concentration (mg%)
20 100

100-199


200-299

ataxia
tolerance

Alcohol intoxication
Blood alcohol
Clinical presentation
concentration (mg%)
300-399
severe dysarthia

400-799
Coma ,hypothermia
,hypotension , hyporeflexia (aspirate) ,apnea
600-800

Alcohol intoxication
B1
, B1

, 30
-60



haloperidol 2.5- 5 mg

Alcohol withdrawal

Alcohol withdrawal

,
neurotransmitter

Sympathetic autonomic nervous system

Alcohol withdrawal syndrome

Alcohol withdrawal
6 8 hr :

Hypersympathetic activity :

8 12 hr : perceptual symptom
Mild case

:perceptual distortion
Severe case
:psychotic and perceptual symptom
(delusion,illusion and hallucination)

Alcohol withdrawal
12 24 hr :

Grand mal seizures ( > 1 attack in 1-6 hr from first)

< 3% can be status epilepmaticus

withdrawal seizure

alcohol withdrawal
delirium

Alcohol withdrawal
72 96 hr :

Mild case
Severe case

:
:alcohol withdrawal delirium

Alcohol withdrawal delirium

(disorientation)

Alcohol withdrawal

Hepatic encephalopathy , congestive heart

failure, Acute hepatitis ,Acute pancreatitis
Suicidal risk ,
Psychosis ,Severe depression
Alcohol withdrawal
AWS(Alcohol Withdrawal Scale) ,CIWA-AR(Clinical Institute
Withdrawal Assessment of Alcohol Scale)

Alcohol withdrawal

fluid,
electrolytes

magnesium sulfate hypomagnesemia

multivitamins thiamine (100 mg/day)

complete blood count, liver

function tests, ,
alcohol electrolytes

Alcohol withdrawal
(Alcohol detoxification)

GOAL :
benzodiazepines Cross-tolerant

Lorazepam
Lorazepam : Diazepam : Chlordiazepoxide
1mg
: 5mg : 10mg

Alcohol withdrawal
(Alcohol detoxification)

benzodiazepines 2
fixed-schedule regimen
withdrawal
symptom-triggered regimens
( CIWA-Ar)
symptom-triggered regimens

Alcohol withdrawal
(Alcohol detoxification)
Fixed-schedule regimen (Structured Medicaton Regimens)
Chlordiaxepoxide

50 mg q 6 hr * 4 dose then 25 mg q 6 hr * 8 dose

Diazepam 10 mg q 6 hr * 4 dose then 5 mg q 6 hr * 8 dose
Lorazepam (helpful in old aged and liver disease) 2 mg q 6 hr * 4 dose
then 1 mg q 6 hr * 8 dose

Alcohol withdrawal
(Alcohol detoxification)
Symptom-triggered regimens

(PRN dosing)

CIWA-Ar, AWS (

CIWA-Ar)
symptom-triggered regimens

Alcohol withdrawal delirium(DTs)

Alcohol withdrawal delirium(DTs)

Diazepam Lorazepam
5-15

DTs 7-10
10%

Alcohol-induced Persisting Amnestic

Disorders
short term memory Wernickes

encephalopathy Korsakoffs Syndrome

Wernickes encephalopathy syndrome:

1.Dementia
2.Ataxia
3.Nystagmus, Opthalmoplegia(CNVI)
thiamine 100 mg im OD opthalmoplegia

Alcohol-induced Persisting Amnestic

Disorders

Korsakoffs Syndrome:
Anterograde and Retrograde amnesia
Confabulation
chronic type of Wernickes encephalopathy syndrome
thiamine 3 12

Relapse Prevention

Relapse Prevention
2
1. Aversion therapy:

1. Disulfiram(Antabuse)
2.
3. Anti depressant

2. Group therapy:
1. Self-help group
2. Alcoholic Anonymous, AA group

Aversion therapy
Disulfiram(Antabuse)
Aldehyde dehydrogenase

Aldehyde


30

Aversion therapy
Disulfiram(Antabuse)
Aldehyde dehydrogenase

Aldehyde


30

250 -500 mg

Aversion therapy

Naltrexone
1. Opiate antagonist (Naltrexone)

50 mg

2. Acamprosate
Glutamate

3. Antidepressant