Download Alcoholism

Ternopil State Medical
University
named I.Horbachevsky
Chair of neurology, psychiatry,
narcology and medical psychology
Prep. by Roksolana Hnatyuk
M.D., Ph.D.
Alcoholism,
Nicotine Addiction, Cannabis
Compound Abuse
Alcoholism
 Alcoholism is the consumption of or
preoccupation with alcoholic beverages to the
extent that this behavior interferes with the
alcoholic's normal personal, family, social, or
work life.
 The chronic alcohol consumption caused by
alcoholism can result in psychological and
physiological disorders. Alcoholism is one of the
world's most costly drug use problems; with the
exception of nicotine addiction, alcoholism is
more costly to most countries than all other drug
use problems combined.
 While alcohol use is required to trigger
alcoholism, the biological mechanism of
alcoholism is uncertain. For most people,
moderate alcohol consumption poses little danger
of addiction. Other factors must exist for alcohol
use to develop into alcoholism. These factors may
include a person's social environment, emotional
health and genetic predisposition. In addition, an
alcoholic can develop multiple forms of addiction
to alcohol simultaneously such as psychological,
metabolic, and neurochemical. Each type of
addiction must be treated individually for an
alcoholic to fully recover.
What is alcoholism?
 Alcoholism, also known as alcohol dependence, is
a disease that includes the following four
symptoms:
 Craving--A strong need, or urge, to drink.
 Loss of control--Not being able to stop drinking
once drinking has begun.
 Physical dependence--Withdrawal symptoms,
such as nausea, sweating, shakiness, and anxiety
after stopping drinking.
 Tolerance--The need to drink greater amounts of
alcohol to get "high."
Epidemiology
 Substance use disorders are the major
public health problem facing many
countries. In the United States today, more
than 15 million Americans are estimated to
suffer from alcoholism. "The most common
substance of abuse/dependence in patients
presenting for treatment is alcohol.”
 In the United Kingdom, the number of
'dependent drinkers' was calculated as over
2.8 million in 2001.
 In the US: These statistics are based on the US National
Longitudinal Alcohol Epidemiologic Study. Alcoholism is
prevalent in 20% of adult hospital inpatients. One in 6 patients
in community-based primary care practices had problem
drinking. The following apply to the US adult population:
 Current drinkers - 44%
 Former drinkers - 22%
 Lifetime abstainers - 34%
 Abuse and dependency in the past year - 7.5-9.5%
 Lifetime prevalence - 13.5-23.5%
 Four percent of the global burden of disease is attributable
to alcohol. This figure rises to 7% in North America,
Europe, Japan, and Australia and to 12% in Eastern Europe
and Central Asia. Worldwide, alcohol is responsible for a
percentage of a number of conditions, as follows:
 Cirrhosis - 32%
 Motor vehicle accidents - 20%
 Mouth and oropharyngeal cancers - 19%
 Esophageal cancer - 29%
 Liver cancer - 25%
 Breast cancer - 7%
 Homicides - 24%
 Suicides - 11%
 Hemorrhagic stroke - 10%
Identification and diagnosis
 Identification of alcoholism may be difficult
because there is no detectable physiological
difference between a person who drinks a lot and a
person who can't control his or her drinking.
Identification involves an objective assessment
regarding the damage that imbibing alcohol does
to the drinker's life compared to the subjective
benefits the drinker perceives from consuming
alcohol. While there are many cases where an
alcoholic's life has been significantly and
obviously damaged, there are still a large number
of borderline cases that can be difficult to classify.
Genetic predisposition testing
 At least one genetic test exists for an allele that is
correlated to alcoholism and opiate addiction.
Human dopamine receptor genes have a detectable
variation referred to as the DRD2 TaqI
polymorphism. Those who possess the A 1 allele
(variation) of this polymorphism have a small but
significant tendency towards addiction to opiates
and endorphin releasing drugs like alcohol.
Although this allele is slightly more common in
alcoholics and opiate addicts, it is not by itself an
adequate predictor of alcoholism.
 Possible causes or contributors to alcohol-related
psychosis include the following:
 Chronic alcoholism
 Thiamine deficiency (eg, diet, starvation, emesis, gastric
tumor)
 Alcohol-dependent withdrawal early-stage (8-24 h) or latestage (36-72 h) (Monitor temperature at least every 4 h.)
 Comorbid substance abuse (Therefore, do an extensive
toxicology screen.)
 Lack of psychosocial supports
 Comorbid psychotic and mood disorders
 Alcoholic idiosyncratic intoxication (pathological
intoxication)
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Impulse control disorder
Advanced age
Early onset of alcohol use
 Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition (DSM-IV)
criteria are required to make the diagnosis of alcohol
dependence. The diagnosis requires 3 of the 8 criteria in
the DSM-IV. The diagnosis of alcohol dependence relies
more on the consequences of alcohol use and less on the
amount of alcohol consumed. Thus, if one suspects alcohol
problems from answers to screening questions, attempt to
determine what consequences of alcohol abuse the patient
has experienced. The following are diagnostic factors
outlined by the DSM-IV:
• Continued drinking despite physical or psychological consequences
caused or exacerbated by alcohol
• Neglect of other activities
• Inordinate time spent drinking and recovering
• Drinking more or over a longer period than intended
• Inability to control drinking
• Tolerance (defined as increased amounts needed for effect)
• Withdrawal symptoms on cessation of alcohol
• Drinking to relieve or avoid withdrawal symptoms
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The following 5 reasons illustrate the
importance of screening for alcohol and drug
abuse:
• Alcoholism is common and serious.
• Failure to screen leads to misdiagnosis.
Approximately 50-90% of alcohol problems are
missed in the office.
• Effective and simple screening tests are available.
• Effective treatments are available, especially if the
diagnosis is made early.
• Early identification can prevent physical and
psychosocial problems.
 Physical:
 The following are signs and symptoms of
alcohol withdrawal:
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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.
 The following are signs of delirium
tremens (ie, alcohol withdrawal
delirium):
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Tachycardia and hypertension
Temperature elevation
Delirium
 The following are signs of chronic
alcoholism:
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Gynecomastia
Spider angiomata
Dupuytren contractures (also may be
congenital)
Testicular atrophy
Enlarged or shrunken liver
Enlarged spleen
 Ataxia, ophthalmoplegia (usually lateral
gaze palsy), and confusion indicate
Wernicke encephalopathy.
 Anterograde and retrograde amnesia, often
with confabulation and preceded by
Wernicke encephalopathy, indicates
Korsakoff syndrome.
 Asterixis and confusion suggest hepatic
encephalopathy.
 Causes: Patients commonly use a
psychiatric disorder to deny alcohol abuse.
Unless strong evidence indicates that the
psychiatric disorder clearly precedes the
alcoholism or is present during a long
period of sobriety, the best plan is to
proceed as if alcoholism is the primary
diagnosis. Arrange a consultation with a
psychiatrist for difficult cases because some
patients who are treated for psychiatric
conditions stop drinking and do very well.
 Genetic psychiatric disorders, such as
schizophrenia and bipolar disorder, are
associated with alcoholism. The presence of
both a serious, persistent mental illness and
alcoholism is called dual diagnosis. The
physician must address both. Family history
commonly reveals members with bipolar
disorder, alcoholism, or both. Despite this and
despite an intensive search for a gene for
alcoholism, study results remain inconclusive.
Nevertheless, some evidence indicates that
genetics plays a major role in alcohol abuse.
 Treatment of alcoholism involves the following:
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Brief physician advice makes a difference.
While a trial period of controlled drinking with careful
follow-up might be appropriate for a diagnosis of
alcohol abuse, this approach increases a physician's
professional liability. Complete abstinence is the only
treatment for alcohol dependence. Emphasize that the
most common error is underestimating the amount of
help that will be needed to stop drinking. The
differential diagnosis between alcohol abuse and
dependence can be a difficult judgment call.
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 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 meetings
regularly (daily at first) and for a sufficient length of time
(usually 2 y or more) because recovery is a difficult and
lengthy process.
 In the beginning of treatment, and perhaps ongoing,
patients should remove alcohol from their homes and avoid
bars and other establishments where strong pressures to
drink may influence successful abstinence.
 If the patient has an antisocial personality (ie, severe
problems with family, peers, school, and police before age
15 y and before the onset of alcohol problems), recovery is
less likely. If the patient has primary depression, anxiety
disorder, or another potentially contributory disorder (The
other disorder must antedate the problems with alcohol or
it must be a significant problem during long periods of
sobriety.), treat this primary problem aggressively.
Nicotine Addiction
 Cigarette smoking is a major preventable cause of disease
worldwide, and it is the major cause of premature death in
North America. In 1912, Adler first suggested that
inhalation of cigarette smoke might be a cause of lung
cancer. Since then, knowledge about the adverse health
effects of smoking has accumulated.
 The important causes of mortality are atherosclerotic
vascular disease, cancer, and chronic obstructive
pulmonary disease (COPD). Smoking also can contribute
to other diseases, eg, histiocytosis X, respiratory
bronchiolitis, obstructive sleep apnea, idiopathic
pneumothorax, low birth weight, and perinatal mortality.
 Pathophysiology: Nicotine releases hormone noted in the
following paragraphs that act on various receptors in the
brain. Nicotine use results in more efficient processing of
information and reduction of fatigue. In addition, nicotine
has a sedative action, reduces anxiety, and induces
euphoria. Nicotine effects are related to absolute blood
levels and to the rate of increase in drug concentration at
receptors.
 Nicotine stimulates the hypothalamic-pituitary axis; this, in
turn, stimulates the endocrine system. Continually
increasing dose levels of nicotine are necessary to maintain
the stimulating effects. With regards to dependence, some
experts rank nicotine ahead of alcohol, cocaine, and heroin.
A teenager who smokes as few as 4 cigarettes might
develop a lifelong addiction to nicotine.
 In the US: In 1965, 52% of men and 34%
of women were cigarette smokers.
Presently, the incidence of cigarette
smoking has decreased to 28% and 24%,
respectively. The incidence of smoking is
highest in afro-americans, blue-collar
workers, less-educated persons, and persons
in the lower socioeconomic strata.
History:
 Nicotine addiction is classified as nicotine use disorder
according to the Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition, Text Revision (DSM-IVTR). The criteria for this diagnosis include any 3 of the
following within a 1-year time span:
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Tolerance to nicotine with decreased effect and increasing dose to
obtain same effect
Withdrawal symptoms after cessation
Smoking more than usual
Persistent desire to smoke despite efforts to decrease intake
Extensive time spent smoking or purchasing tobacco
Postponing work, social, or recreational events in order to smoke
Continuing to smoke despite health hazards
Physical:
 Physical effects of nicotine use include
increased heart rate, accelerated blood
pressure, and weight loss.
 Physical effects of nicotine withdrawal and
smoking cessation include weight gain due
to increase in appetite, decreased heart rate,
and improvement in the senses of taste and
smell.
Opioid Abuse
 Background:
 Opioids are the most powerful known pain
relievers. Their use and abuse date back to
antiquity. The pain relieving and euphoric effects
of opioids were known to Sumerians (4000 BC)
and Egyptians (2000 BC).
 International awareness of opioid abuse was
stimulated early in the 20th century when
President Theodore Roosevelt convened the
Shanghai Opium Commission in 1909 to aid the
Chinese empire in stamping out opioid addiction,
especially opium smoking.
Cannabis Compound Abuse
(marijuana)
 Background:
 The earliest references to marijuana include use by Chinese
emperors in 1000 BC. In classical literature, Homer's Iliad
records the gift of marijuana from Helen to Telemachus.
 Marijuana was introduced to the Western Hemisphere in the
early 1500s. African slaves brought marijuana plants with them
to the Portuguese colony of Brazil, while the Spaniards began
growing it in Chile.
 Cannabis was introduced to the Virginia colony of Jamestown
in 1611 and to the Massachusetts Bay Colony in 1629.
Although primarily used as a source of fiber, cannabis
occasionally was smoked. Cannabis began to be used
medicinally and was grown by many American planters. By
1850, it was listed in the US Pharmacopoeia.
Frequency:
In the US: Marijuana remains the most commonly
used illicit drug in the United States. According to
data from the 1998 National Household Survey on
Drug Abuse (NHSDA), more than 72 million
Americans (33%) aged 12 years and older have
tried marijuana at least once in their lifetimes.
Overall, rates of marijuana use appear to be
increasing. Recent figures from the National
Institute on Drug Abuse (NIDA, 1999) show that
almost 50% of 12th-grade students have used
marijuana.
The following symptoms may be
prominent in acute intoxication of
cannabis:
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Euphoria
Relaxation
Subjective feelings of well-being or grandiosity
Perceptual changes (including visual distortions)
Drowsiness and sluggishness
Diminished coordination
Paradoxical hyperalertness
A subjective sense of slowing of the passage of time
Increased appetite (the "munchies")
 Although commonly misperceived as universally resulting
in a relaxed and euphoric state, cannabis intoxication can
produce a dysphoric reaction. Carefully examine patients
for evidence of suicidality and homicidality, document
presence or absence thereof, and manage as indicated.
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Feelings of panic
Disorientation and memory impairment (rare; usually
occurs only after ingestion of high-potency cannabinoid
preparations)
Paranoia
Mood lability
Altered perceptions (following heavy marijuana use)
manifesting as illusions or frank hallucinations, most
often visual in type
Depersonalization
Psychotic episodes
Dysphoria
Recurrence of psychosis in patients with schizophrenia
 Physical: Physical signs and symptoms reflect
the effects of marijuana on multiple organ
systems and can be classified according to the
system involved.
 Effects on central and peripheral nervous systems: Cannabisinduced cerebral atrophy or neuropsychological impairment
remains a controversial diagnosis. Chronic effects of long-term
marijuana use may be related to marijuana's significant fat
solubility resulting in high blood levels of the drug after
extended use. Marijuana-induced seizures have been described.
Studies using simulated driving and flying situations have
shown that the use of cannabis has a profound effect on
estimations of time and distance and causes impairment of
attention and short-term memory. These effects are still
discernible 24-48 hours after use of the drug.
 Effects on respiratory system:
Cannabis smoke contains carcinogens similar
to those found in tobacco smoke, and
chronic heavy marijuana use may
predispose people to chronic obstructive
lung disease. Some studies indicate that
pulmonary neoplasms are more common
among habitual marijuana users; however,
confounding by cigarette smoking limits the
interpretability of some of these reports.
 Effects on cardiovascular system:
Acute intoxication may induce tachycardia and orthostatic
hypotension.
 Effects on reproductive system:
 Marijuana has been linked to infertility. In vitro studies
have reported abnormal cell division and abnormal
spermatogenesis resulting in decreased sperm counts;
however, the effects of marijuana on human fertility
remain unclear. In females, marijuana use may increase the
number of anovulatory cycles. In males, marijuana use
may cause a decrease in follicle-stimulating hormone,
resulting in a decrease in testosterone production and,
possibly, testicular atrophy.
 Effects on gastrointestinal tract:
Marijuana has known antinausea properties and the use of
marijuana has been permitted for the treatment of nausea in
some US states for this reason.
 Causes:
 Risk factors for use
 Young age
 Availability (may be affected by cultural
and geographic factors, eg, urban
environments)
 Comorbid alcohol abuse and/or
dependence
 Comorbid drug abuse
Thank you for attention!