Alcoholism and Addiction: Medical Issues

Eric Lind Johnson, M.D.

Assistant Professor Department of Family and Community Medicine UNDSMHS Altru Health System

Objectives • Review basic physiology, signs, and symptoms related to alcoholism • Review common medical complications and their treatment in alcoholism • Understand resources available for treatment of alcoholism

Alcohol/Ethanol • Mechanisms of Toxicity – CNS depressant – Teratogen – Carcinogen

Basic Alcohol Physiology • 25% enters the bloodstream from the stomach, 75% from the intestine • 90% to 98% is removed in the liver, and the remainder is excreted by the kidneys, lungs, and skin. • 70-kg man can metabolize 5 to 10 g ethanol per hour (average drink contains 12 to 15 g ethanol)-alcohol dehydrogenase 90%

Blood Ethanol Levels

Blood Ethanol Level 50-100 Sporadic Drinkers Chronic Drinkers Euphoria, gregariousness, incoordination Minimal or no effect 100-200 200-300 Slurred speech, ataxia, labile mood, drowsiness, nausea Sobriety or incoordination Euphoria Lethargy, combativeness Stupor, incoherent speech, vomiting Mild emotional and motor changes 300-400 Coma Drowsiness >500 Death Lethargy, stupor, coma

adapted from Goldman: Cecil Textbook of Medicine, 21st ed., Copyright © 2000 W. B. Saunders Company

Medical Model of Alcoholism •

Signs

: • Heavy recurrent alcohol use and/or intoxication • Other drug use or unexpected drug responses or interactions • Trauma • Absenteeism, presenteeism • Personal neglect

Medical Model of Alcoholism •

Symptoms

: • Nausea, vomiting • Unexplained diaphoresis • Tachycardia • Seizures, hallucinations • Withdrawal, tremors, blackouts • Depression, anxiety, sleep disturbance • Erectile dysfunction in men

Medical Model of Alcoholism • Etiology: Familial-Heritability estimated at 40-60% • Less in certain populations (i.e. southeast Asians) • Possibly more damaging for women

Signs/Symptoms of Suspected Alcoholic Patient in a Clinic Setting • Fatigue • Absenteeism/Presenteeism • Depression/Anxiety/Psychosocial Issues • (Family History) • Obesity • Hypertension • Hepatomegaly • Gastrointestinal Complaints • None

Initial Laboratory Evaluation of Suspected Alcoholic Patient • Blood alcohol (drug screen) • LFT’s (GGTP) • elevated MCV • elevated triglycerides These may be totally unrevealing….

Medical Complications • GI tract/Liver: Fatty liver, hepatitis, cirrhosis, esophagitis, gastritis pancreatitis, cancers • Nervous system: Brain: Hepatic encephalopathy, Wernicke-Korsakoff syndrome(thiamine deficiency), cerebellar degeneration, central pontine myelinolysis, dementia

Medical Complications • Nutrition: Deficiencies of Vitamins: Folate, thiamine, pyridoxine, niacin, riboflavin Minerals: Magnesium, zinc, calcium Protein • Metabolites and electrolytes Hypoglycemia, ketoacidosis, hyperlipidemia, hyperuricemia, hypomagnesemia, hypophosphatemia

Medical Complications • Neuromuscular: Neuropathy, myopathy • Cardiovascular: Arrhythmia, cardiomyopathy, Hypertension • Bone marrow: Macrocytosis, anemia, thrombocytopenia, leukopenia

Medical Complications • Endocrine: Pseudo-Cushing's syndrome, testicular atrophy, amenorrhea, DM?, Osteopenia/osteoporosis • Other cancers? (i.e., breast) • Traumatic injury • Fetal alcohol syndrome

Fetal Alcohol Syndrome •

1 to 3 births per 1,000 world wide

•

1968 first association by French researchers at the University of Nantes

•

Early 1970’s FAS as condition – University of Washington

•

4,000-12,000 infants per year in US

Fetal Alcohol Syndrome • NO use of alcohol in pregnancy is safe • Microcephaly, distinctive facial features, developmental delay, behavioral disorders.

• Occurs in about 6 percent of children of alcoholic women • Fetal alcohol effect-more common, more subtle

Detoxification and Withdrawal Syndromes

Alcohol Overdose • ABC’s • Oxygen, assisted ventilations • Intubate • IV, infuse fluid to support perfusion • Lavage if within 2 hours

Alcohol Overdose – Dextrose, Oxygen, Narcan, Thiamine – Glucose, thiamine (50-100mg) – Narcan may reduce respiratory depression but not CNS depression (? Use) • Dialysis - removes 280mg/minute

Treatment of Initial Withdrawal and Agitation Benzodiazepines: • Diazepam • Lorazepam • Chlordiazepoxide Neuroleptics: • Phenothiazines may be used as adjunct to benzodiazepines

Detoxification • Severe Withdrawal (Delirium Tremens) occurs about 3-7%. High mortality. May occur

days

after last use. BP, pulse good indicators.

• Long acting benzodiazepines (Librium), IV fluids, Thiamine, Multivitamin all started on admission.

Co-Morbid Conditions • Medical • Psychiatric: Depression, Anxiety, or Bipolar Disorder common • SSRI’s have the most data in Treatment of Depression in this population

Medical Treatment of Alcoholism

Treatment of Alcoholism • Traditional Inpatient/Outpatient • 12 step: AA(oldest, common), Specialty groups • Medication • Usually a combination of all 3

Medications for Alcohol Dependence • Three oral medications (approved) -Naltrexone -Acamprosate -Disulfiram • One injectable medication (approved) -Extended-release injectable naltrexone

Medications for Alcohol Dependence • Topiramate (off label) Also used for bipolar disorder • Future directions -Endocannibinoid receptor blockers -Nicotinic receptor agonist/antagonist • Combining medications uncertain benefit

Medication Management • Consider in those failing typical psychosocial approaches • Used typically in those whose program includes abstinence from alcohol • Combining Medications and Behavioral Interventions (COMBINE) clinical trial -Benefit medications/counseling combined • Medications usually prescribed 6 to 12 months • Twice weekly brief counseling efficacious

Naltrexone • Blocks opioid receptors • Oral or injection • 28% relapse rate vs 46% with placebo

Acamprosate • GABA and glutamate receptors • 17 clinical trials • 36% abstinent vs 23% on placebo • Better results in European trials (more dependent patients?) • Can’t use in liver disease

Disulfuram • Interferes with alcohol metabolism, increases aldehyde concentrations results in flushing, nausea, vomiting • Poor compliance is typical • Maybe better in short-term high-risk situations

Topiramate • GABA, glutamate receptors (?) • Some efficacy in those not abstinent at start of medication • Used for other psych disorders

Alcohol Treatment • Typically a cognitive-behavioral model • Motivational Interviewing • Stages of Change • Often incorporate some “12 step” concepts

“12 Step” Groups • AA oldest, founded 1935 • Founders were acquainted with Carl Jung • Mentoring (“sponsor”) encouraged • Not “group” therapy • Members are encouraged to seek outside help, physician, clergy, psych, etc.

• No cost (voluntary donations)

Outcome Predictors • Severity of addiction or withdrawal • Psychiatric Co-morbidity • Substance Related Problems • Multiple Substance Abuse • Length of Treatment • Genetic • Socio-Economic Psychiatric Clinics N Am 26 (2003) 381–409

Summary • Effective alcohol screening and guidelines • Medications appropriate for some • Medications not a substitute for traditional psychosocial interventions/resources • Combination of above likely more effective