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#+AUTHOR: Armin Moradi
#+TITLE: Alcohol from 10,000 ft
#+DATE: 2020-08-07
* Epidemiology
- 90%
- 60-70%
- 40%+
- 10/5%
- 100000
#+BEGIN_NOTES
- 90% of the population in the US drink at some point
- 60-70% are current drinkers
- more than 40% have had temporary problems as a result of their alcohol use
- 10% of males and 5% of females have met criteria for alcohol use disorder in their lifetime
- 100,000 deaths annually in the US as a result of alcohol abuse
- so, it's a pretty serious problem, and we see a lot of patients with alcohol and other substance use disorders
#+END_NOTES
* Comorbidity
- Antisocial
- Mood
- Anxiety
- Suicide
#+BEGIN_NOTES
- Antisocial personality disorder and alcohol use disorder have been linked
- some studies suggest that antisocial personality disorder is particularly common in men with alcohol related disorders
- no causative link has been found, and other studies suggest there is no link
- so, massive rock of salt
- about 30-40% of people with alcohol related disorders have at some point met criteria for MDD
- MDD is more likely in females, and in daily users with a family hx of alcohol use disorder
- Patients with Bipolar I also have been found to be at higher risk of alcohol use disorder
- the hypothesis is that they do it as a form of self-medication
- Many people use alcohol for its effect in alleviating anxiety
- pretty much a form of self-medication
- about 25-50% of people with alcohol use disorder also meet criteria for an anxiety disorder
- so spidey senses should be flying every which way to screen for anxiety disorders in someone with alcohol use disorder
- Particularly phobias and panic disorders are common
- interestingly, alcohol use and alcohol related disorders generally preceed development of GAD and panic disorder
- causative? maybe
- Suicide, ranges about somewhat approximately between 10-15%, although alcohol use itself may be involved in more
- Other factors involved include living alone, unemployment, weak support, coexisting medical condition, and MDE
#+END_NOTES
* Etiology
- Bio
- Psycho
- Social
#+BEGIN_NOTES
- Genetic influences reign supreme: 3-4x higher risk in first degree relatives
- risk increases with the number of alcoholic relatives and closeness of genetic composition
- very wow concordance rates in identical twins
- adoption studies have also found genetic link
- psychological theories propose that alcohol is used to reduce tension, increase feelings of power and decrease psychological pain
- as a coping strategy
- interestingly, the tension reducing effects are evident at low doses
- at high doses, minimal change in tension level was noted
- so, it's hypothesized that this theory is actually unlikely
- psychodynamic theories suggest alcohol is a way to deal with self-punitive harsh superegos and to decrease unconscious stress levels
- behavioural theories suggest using alcohol is about expectations regarding the rewarding effects of drinking, cognitive attitudes toward responsibility for one's behaviour, and subsequent reinforcement after intake
- the social side of things relates to cultural norms, for example jews introduce children to alcohol in a family environment in small to moderate amounts have found to be less alcoholic
- but these are also stereotypes, and inaccurate at best
#+END_NOTES
* Absorption
- 10% stomach
- 90% small intestine
- 30-90min lag (usually 30-45mins)
- most rapid 15-30% alcohol
- too high of a concentration: pylorospasm -> N/V
* Metabolism
- 90% liver oxidation -> constant rate ~10-34mg/dL/hr
- 10% kidney and lungs
- alcohol dehydrogenase: alcohol -> acetaldehyde (toxic)
- aldehyde dehydrogenase: acetaldehyde -> acetic acid
* Effects
- fly high
- wings better than redbull
#+BEGIN_NOTES
- So, alcohol, obviously the best drug of all time...
- but seriously
#+END_NOTES
* Effects 2.0
- Brain
- Behaviour
- Sleep
#+BEGIN_NOTES
- no single molecular target
- affects neuronal membranes -> become rigid/stiff -> dysfunctional
- 5-HT3, GABA-A enhanced
- glutamate receptor and voltage gated Ca channels inhibited
- behaviour-wise, acts as a depressant much like benzos and barbiturates
- has cross-tolerance and cross-dependence with those
- Evening consumption -> ease of falling asleep, but adverse effects on architecture of sleep
- decrease in REM and deep sleep, and more sleep fragmentation
- therefore, the idea that drinking alcohol helps persons fall asleep is a myth
#+END_NOTES
* Effects 2.0 cont'd
- 0.05% -> thought, judgement, restraint are loosened
- 0.1% -> clumsy voluntary motor actions
- 0.1-0.15% -> legal intoxication
- 0.2% -> entire motor depression
- 0.3% -> confusion and stupor
- 0.4-0.5% -> coma
- >0.5% -> death due to respiratory depression, aspiration, etc
* Dependence
- Alcohol use disorder: DSM-V
- So many types!
#+BEGIN_NOTES
- I'll defer the diagnostic criteria to DSM-V
- But there are quite a few types and categories of alcohol dependence
- Type A: late onset, few childhood risk factors, mild dependence
- Type B: opposite of that
- Early stage problem drinkers, affiliative drinkers, schizoid-isolated drinkers
- gamma alcohol dependence (active in AA, control problems once started)
- delta: must drink a certain amount each day but unaware of dependence until they must stop
- Type I male limited: more psychological dependence + guilty, late onset
- Type II male limited: socially-disruptive, spontaneous seeking, early stage
- antisocial alcoholism: close association with antisocial PD
- developmentally cumulative alcoholism: primary tendency + cultural norm
- negative-affect alcoholism: mood regulation, women
- developmentally limited alcoholism: binge, less frequent as ages
#+END_NOTES
* Withdrawal
- tremulousness
- psychotic and perceptual symptoms
- seizure
- delirium tremens
- irritability
- GI symptoms (N/V)
- sympathetic hyperactivity
#+BEGIN_NOTES
- classic sign is tremulousness, develops about 6-8 hours
- it can be similar to physiological tremor >8Hz and great amplitude
- perceptual symptoms begin 8-12 hours
- seizures in 12-24 hours
- DT anytime during first 72 hours until 1 week
- sympathetic hyperactivity: anxiety, arousal, sweating, flushing, mydriasis, tachycardia, HTN, startle easily
#+END_NOTES
* Withdrawal treatment
- Benzodiazepines
#+BEGIN_NOTES
- benzos for controlling seizure, delirium, anxiety, tachy, HTN, diaphoresis, tremor
- No IM -> erratic absorption
- start with a high dose and titrate down as opposed to the other way around
- carbamazepine is also useful + minimal abuse liability (800mg/day)
- clonidine for sympathetic hyperactivity
- neither for seizure or DT -> only benzos
- DTs usually start after 5-15 years of use, and in 30-40s
- DT -> prevention is the name of the game
- CIWA with benzos
- avoid antipsychotics -> reduce seizure threshold
- warm and supportive psychotherapy
- high calorie high carb diet
- once DT appears: chlordiazepoxide 50-100 q4h or lorazepam IV
#+END_NOTES
* All done
^_^