alcohol & amphetamines
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Alcohol & Amphetamines
John R. MartinelliMSIII, SGUSOMBergen Regional Medical CenterDepartment of Psychiatry
Alcohol
Statistics (WHO)
• Globally: 6%
• N. America, Europe, Japan, Australia: 7%
• Eastern Europe and Central Asia: 12%
• UK: 1 in 3 patients = 33%
Statistics (USA)• 3rd leading cause of preventable death• 85,000 deaths per year• 20% of adult hospital inpatients• 1 in 6 patients in community-based primary care practices• More common in lower income and less educated groups• Transition highest for nicotine users>cocaine>alcohol>MJ• Transition risk to dependence among psychiatric patients• M:F = 2.5:1• NativeA > LatinA > WhiteA > AfricanA > AsianA• Cost of $185,000,000,000 (billion)
Diagnosis• CAGE
– Concern– Annoyed– Guilt– Eye Opener
Yes to 2 or more questions =>
Specificity of 76% and a sensitivity of 93% for the identification of excessive drinking
Specificity of 77% and a sensitivity of 91% for the identification of alcoholism
Diagnosis
–Contains 10 questions, 5 possible answers scored 0-4
–Greater sensitivity in populations with a lower prevalence of alcoholism
–Cut-off of 5 -> sensitivity of 84% and specificity of 90%
• AUDIT
Etiology
• Early Onset– Genetic Predisposition
• Late Onset– Psychosocial Factors
Pathophysiology
• Opioids, GABA, glutamate, serotonin, and dopamine
• Elevates opioid levels -> euphoria
• GABA potentiation -> anxiolytic and sedative effects
• Every cellular/organ system (NADH)
• High doses -> coma and death
Pathophysiology
• Cravings– EtOH increases opioid receptors– Potentiates cravings upon discontinuation
• Withdrawal– EtOH inhibits the receptor for glutamate– Long-term -> up-regulation glutamate receptors– Potentiates CNS excitability upon discontinuation
Comorbidities• WHO
– Cirrhosis – 32%– Esophageal cancer – 29%– Liver cancer – 25%– Homicide – 24%– Motor vehicle accidents – 20%– Mouth and oropharyngeal cancers – 19%– Suicide – 11%– Hemorrhagic stroke – 10%– Breast cancer – 7%
• Folate Deficiency/Anemia• Hypertriglyceridemia/Hypercholesterolemia• Bone Marrow Suppression/Immunosuppression• Fetal Alcohol Syndrome• Wernicke – Korsakoff Syndrome• Delirium Tremens
Alcoholic Liver Disease
•Progressive inflammatory liver injury•Subacute fever, leukocytosis, jaundice•Marked impairment of liver function (Bili/COAG)•Elevated LFT’s (AST>ALT, GGT)•Hepatic Encephalopathy•Portal HTN•Steatosis/Fatty Liver•Cirrhosis -> Atrophy
Wernicke-Korsakoff Syndrome
Thiamine (B1) Deficiency (PDH complex)
• Confusion• Memory• Ataxia• Nystagmus• Ophthalmoplegia
Fetal Alcohol Syndrome
• Most severe• Characteristic faces• Growth retardation• CNS involvement• Cognitive impairment• Learning disabilities• Behavioral
Treatment• Brief physician recommendation
• Pharmacologic Therapy– Targeting reward centers (naltrexone)– Targeting craving (acamprosate)
• Substance Abuse and Mental Health Services Administration (SAMSA)– 5 stages of change– Precontemplation -> Contemplation -> Preparation ->
Action -> Maintenance– Group/AA/12 Steps
Methamphetamines
“Crystal Meth”“ICE”
Background• Introduced nearly 100 years ago (Asthma/Rhinitis)• Use has increased rapidly last 10 years• 50 million users worldwide• White males 30-40• Increased adolescent abuse• Euphoria & stimulatory effects• Longer effect than cocaine• Similar toxicity as cocaine• Oral, IV, snorted, or smoked• Cheap and easily produced (ephedrine reduction)
Pathophysiology
• CNS stimulant• Catecholamine reuptake inhibitor• MAOI• Blocks presynaptic vesicular storage• IV/IM peak plasma levels @ 30 minutes• PO peak @ 2-3 hours
Signs & Symptoms
• Central nervous system– Headache– Emotional lability, confusion, psychosis, paranoia,
hypersexuality, and hallucinations– Agitation, violent behavior, self-harm– New-onset seizure, movement disorders– Coma
Signs & Symptoms
• Cardiovascular– Chest pain, aortic dissection, MI– Palpitations, tachyarrhythmia– Dyspnea and edema– Hypertension
• Respiratory– Dyspnea– Wheezing– Pneumothorax
Signs & Symptoms• Gastrointestinal– Abdominal pain– Obstruction
• Renal– ATN
• Skin– Delusional parasitosis– Cellulitis, abscess, necrosis
Signs & Symptoms
• Dental Caries
– Peridental abscess
– METH Mouth
Diagnosis
• Clinical Signs & Symptoms
– History– R/O medical condition– Urine toxicology
Treatment
• Toxicity/Overdose– ABC’s– PEG if toxic oral ingestion– Charcoal if suspect contaminants– Correction of hypertension, hypotension,
hyperthermia, metabolic and electrolyte abnormalities
– Control severe psychiatric agitation (Haloperidol vs Atypicals, Benzo’s, Labetalol)
Treatment
• Difficult to remove patient from subculture
• Detox not associated with decreased abuse
• Residential rehabilitation slight efficacy
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