Alcoholism and

substances abuse
Myriam I. Garcia, MD
Internal Medicine Board Certified
Alcohol
Introduction

85,000 death a year in US

National Institute on Alcohol Abuse and

Alcoholism:
M < 65 y/o  > 14 drinks/W or >4 drinks/d
W and M > 65  7 drinks/W or >3 drinks/d

Third leading preventable cause of death

Alcohol Abuse vs Dependance
Abuse Dependance
• Failure to fulfill major responsibilities • Craving
• Drinking in physically dangerous • Loss of control
situations
• Physical dependancce
• Recurrent alcohol related legal
problems • Tolerance
• Continued drinking despite • Withdrawal
relationship problems
DSM-5 Criteria for Alcohol use Disorder
Mild: Two to three criteria
• Failure to fulfill role obligations Moderate: Four to five criteria
Severe: Six or more criteria

• Recurrent drinking in hazardous situations

• Continued drinking despite alcohol-related social or interpersonal

problems

• Evidence of tolerance

• Evidence of alcohol withdrawal or use of alcohol for relief or

avoidance of withdrawal
DSM-5 Criteria for Alcohol use Disorder
• Drinking in larger amounts or over longer periods than intended

• Persistent desire or unsuccessful attempts to stop or reduce drinking

• Great deal of time spent obtaining, using, or recovering from alcohol

• Important activities given up or reduced because of drinking

• Continued drinking despite knowledge of physical or psychological problems

caused by alcohol

• Alcohol craving
CAGE Alcohol Abuse Screening Tool
Diagnosis

• Aspartate aminotransferase (AST)

• Alanine aminotransferase (ALT)
• Gamma glutamyltransferase (GGT)
• Mean corpuscular volume (MCV)
Symptoms of Alcohol withdrawal

• Nausea and vomiting

• Diaphoresis
• Agitation and anxiety
• Headache
• Tremor
• Seizures
• Visual and auditory hallucinations: Many patients who are not disoriented—and
who therefore do not have delirium tremens—have hallucinations
Deliriums Tremens

• Tachycardia and hypertension

• Temperature elevation
• Delirium
Withdrawal Minor Symptoms Alcoholic Withdrawal Delirium Tremens
syndrome hallucinations Seizure

Onset of last 6Hrs 12-24 Hrs 48Hrs 48-96Hrs

Drink
Symptoms Insomnia, Visual Tonic clonic Hallucinations,
tremulousness, hallucinations seizures disorientation,
mild anxiety, tachycardia, HTN,
headache, May be Fever, agitation
diaphoresis, Auditory or
palpitations tactile

Tips Give thiamine, Get CT scan Time of onset

folate, MVI, if repeated important
glucose seizures to
r/o ID or
structural
Chronic Alcoholism

• Gynecomastia
• Spider angiomata
• Dupuytren contractures (also may be congenital)
• Testicular atrophy
• Hepatomegalia
• Enlarged spleen
Complications of Alcoholism

• Wernicke encephalopathy: Ataxia, ophthalmoplegia (usually lateral

gaze palsy), and confusion
• Korsakoff syndrome: Anterograde and retrograde amnesia, often
with confabulation and preceded by Wernicke encephalopathy
• Hepatic encephalopathy: Asterixis and confusion
Wernicke
• Needs emergent tx
• Encephalopathy, Confusion
• Oculomotor dysfunction
(Nystagmus); gait ataxia
• Mamillary bodies
• Tx thiamine
– Before Dxt
Korsakoff
• Chronic condition
• Anterograde and retrograde
amnesia
• Confabulation
• Anterior thalamus
• Tx: Rarely recovers;
(acetylcholinesterase
inhibitors/Memantine?)
Wernicke-Korsakoff: Treatment

• Thiamine before glucose!!!!

• IV thiamine 500mg TID for 2 days, then 250mg daily
• Glucose
• Replace magnesium and other vitamins
Treatment
Acute Outpatient
• Prevent further ETOH intake
• Prevent pt from driving or
operating machinery
• Sedation if become agitated
• Transfer to inpatient
Acute inpatient
• Look for withdrawal
• Prevent wernicke-
Korrsakoff
• Benzodiazepine
chlordiazepoxide (Librium)
or diazepam (Valium)
• If severe liver dz
(lorazepam-oxazepam)
• Don’t give seizure
prophylaxis
• Don’t give haloperidol
Chronic Management
• Refer to in-pt Rehab or out-
pt Therapy
• Don’t give Rx w/o
Psychotherapy
• Naloxone(CI:hepatitis) and
acomprosate
(CI:AKI/CKD) decrease
relapse when use with
psychotherapy
• Disulfaram has poor
compliance and not
effective
Treatment of Alcoholism
• Complete abstinence is the only treatment for alcohol dependence
• Hospitalize patients if they have a history of delirium tremens or if they have significant comorbidity
• Consider inpatient treatment if the patient has poor social support, significant psychiatric problems,
or a history of relapse after treatment.
• Strongly recommend Alcoholics Anonymous (AA).
• Encourage hospitalized patients to call AA from the hospital; AA will send someone to talk to them
if the patient makes the contact.
• Patients need to attend AA meetings regularly (daily at first) and for a sufficient length of time
(usually 2 years or more) because recovery is a difficult and lengthy process.
Benzodiazepines
Benzodiazepines
Opioids
Opioid Overdose
Opioids Withdrawal
• Opioid Withdrawal
Treatment
Cocaine
Cocaine Pharmacologic Effects
• Cocaine acts by blocking the reuptake of neurotransmitters, such as norepinephrine,
dopamine, and serotonin, at the synaptic junction, causing accumulation of
neurotransmitters.

• Produces continuous stimulation that leads to the pleasurable effects reported by cocaine
users.

• These effects include feelings of euphoria which are associated with the excess presence
of dopamine, feelings of confidence which are associated with the excess presence of
serotonin, and feelings of energy which are associated with the excess presence of
norepinephrine.
Cocaine overdose
Treatment of cocaine intoxication
• If ACS: oxygen, aspirin, benzodiazepines, nitroglycerin.
• B blockers should be avoided since can leave alpha stimulation unopposed
causing pronounced systemic and coronary vasoconstriction.

• Hypertension: Benzodiazepines, calcium channel blockers,

phentolamine, nitroprusside, and nitroglycerin.
• Phentolamine is an alpha antagonist that counteracts vasoconstrictive effects
of cocaine.
Questions?