Presenter- Dr.

Tesita Sherry
• Alcohol and alcohol content of different
beverages
• Progressive effects of alcohol in terms of BAC
• Dependence- definition and criteria
• Neurochemistry of alcohol dependence
• Alcohol Dependence types
• Assessment and Screening
• Management
• Pharmacologically assisted detoxification
• Treatment of complicated withdrawal
• Relapse prevention- pharmacological methods
• Special groups and co-morbidities
 The term alcohol originally referred to the primary
alcohol ethanol (ethyl alcohol) CH3-CH2-OH, the
predominant alcohol in alcoholic beverages.

 Word 'alcohol' originates from the Arabian term

'al-kuhul', meaning "the kohl" a powder for the
eyes, which later came to mean "finely divided
spirit".
  Expressed as `UNIT’. 1unit=8grams of alcohol.
BEVERAGE ALCOHOL CONTENT(%) UNITS OF ALCOHOL

Ordinary Beer 3% 2 per pint ~16 gm

Strong Beer 5.5% 4 per pint ~32 gm

Extra strong Beer 7% 5 per pint ~40 gm

Table wine 8-10% 7 per bottle ~56 gm

Fortified wines 13-16% 15 per bottle ~120 gm

(sherry, pot, vermouth)

Spirits(whisky, gin, 42% 40 per bottle ~320 gm

brandy, vodka)
 Definition (ICD-10):
A cluster of physiological, behavioural, and
cognitive phenomena in which the use of a
substance takes on a much higher priority for
an individual than other behaviours that once
had greater value.
ALCOHOL DEPENDENCE:
NEUROCHEMISTRY
• Reward
system-
ventral
tegmental area

• Increased
Dopamine –
meso-cortico-
limbic system
• Increased GABA - effects of alcohol,
especially actions on the GABA-A
receptor (GABAA), enhance the acute
sedating, sleep-inducing, anticonvulsant,
and muscle-relaxing properties of
alcohol.

• Dampening of NMDA

• Activation of limbic system, orbitofrontal

cortex and increased mu opiod
receptors- craving
TYPE 1 (75%) TYPE 2
Milieu limited- Male limited-Genetic
Environment predisposed(sons of male
predisposition alcohol dependent persons

Age of onset >26 years Age of onset <=25 years

Both males and females Only males

High harm avoidance Low harm avoidance

Low novelty seeking High novelty seeking
High reward dependence Low reward dependence
 Alpha- Earliest stage, to relieve pain, can
control drinking.
 Beta- Heavy drinkers, drink daily, physical
symptoms, no addiction, can quit, no
withdrawal symtoms.
 Gamma- Loss of control in drinking, physical
dependence, can quit, withdrawal seen
 Delta- Physical dependence, withdrawal
seen, can't quit.
 Epsilon- Final stage of drinking, continual
and insatiable urge to drink (craving) ,
compulsive drinking.
 History (including previous episodes of AW)
 Physical Examination
 Concomitant drug (illicit & prescribed) intake
 Coexisting medical/psychiatric disorders
 Lab investigations-CBC, LFT, INR, PT, urinary drug
screen
 Breath analyser :BAC estimation
A complete alcohol history should include specific
questions concerning:
 Total duration of alcohol consumption,
 Maximal consumption per drinking occasion,
 Frequency of heavy drinking occasions,
 Drinking-related social & legal problems,
 Time of most recent drink,
 Max abstinence period,
 Severity of withdrawal symptoms
 Psychiatric symptoms, and
 Alcohol-related medical problems
 Alcohol Use Disorders Identification Test (AUDIT) is
considered the most accurate alcohol screening
tool for identifying potential alcohol misuse,
including dependence.

 It was developed by the World Health Organisation,

designed initially for use in primary healthcare
settings with supporting guidance.
 Comprises of 10 questions that represent the
three major conceptual domains of intake,
dependence, and problems. Each question
will receive a score from zero to four.

 Score >8 indicating risky drinking patterns.

 Its use has replaced older screening tools

such as CAGE
 The CAGE questionnaire asks the following questions:
1. Have you ever felt you needed to Cut down on your
drinking?
2. Have people Annoyed you by criticizing your drinking?
3. Have you ever felt Guilty about drinking?
4. Have you ever felt you needed a drink first thing in the
morning (Eye-opener) to steady your nerves or to get
rid of a hangover?
 Two "yes" responses indicate that the possibility of
alcoholism should be investigated further.
 The CAGE questionnaire has been extensively validated
for use in identifying alcoholism.
 The Alcohol Problems Questionnaire is a reliable
44-item instrument covering 8 problem domains:
friends, money, police, physical, affective, marital,
children, and work. All questions relate to the past
6 months.
 Newcastle Alcohol-related Problems Scale (NAPS.)
NAPS has the advantage of detecting problems
arising from either the respondent’s or from
someone else’s drinking, potentially allowing a
greater rate of detection.
These scales will not detect all cases where risky
consumption is present.
 Severity of Alcohol Dependence Questionnaire
(SAD-Q) is a more specific twenty-item inventory
for assessing the presence and severity of alcohol
dependence.
 3 sections, scores <30 indicate low to moderate
dependence, >30 indicate high level of
dependence.
 Paddington alcohol test (PAT) is designed to
identify alcohol-related problems amongst those
attending accident and emergency departments. It
was first published in the Journal of Accident and
Emergency Medicine in 1996 in UK.
 The TACE screening tool
1. T Tolerance: how many drinks does it take to
make you feel high?
2. A Have people Annoyed you by criticizing your
drinking?
3. C Have you ever felt you ought to Cut down on
your drinking?
4. E Eye opener: Have you ever had a drink first thing
in the morning to steady your nerves or get rid of
a hangover?
 The TWEAK alcohol screening test is a short, five-
question test which was originally designed to screen
pregnant women for harmful drinking habits.

1. T Tolerance: how many drinks can you hold?

2. W Have close friends or relatives Worried or
complained about your drinking in the past year?
3. E Eye Opener: do you sometimes take a drink in the
morning when you get up?
4. A Amnesia: Has a friend or family member ever told
you about things you said or did while you were
drinking that you could not remember?
5. K(C)Do you sometimes feel the need to Cut down on
your drinking?
 Investigations
and Intervention

 Detoxification

 Rehabilitation
(Relapse prevention)
 Detection using medical history &
clinical indicators
 Common physical conditions such as liver cirrhosis
and pancreatitis are commonly alcohol-induced.
 Subtle signs include work, financial, marital and
relationship problems, domestic violence,
insomnia, depression and anxiety.
 While the above problems are indicative of alcohol
misuse, they are not conclusive.
 Nor does their absence rule out the existence of
risky alcohol consumption.
 State markers of heavy drinking reflect
physiological alterations likely to be observed if the
patient regularly ingests >5 drinks/day over
several weeks.
γ-glutamyltransferase >35.0 IU/L.
 a sensitivity and specificity of 60%
 levels are likely to return to normal after 2 to 4
weeks of abstinence,
 increases of >20% can be useful in identifying
patients who have returned to drinking after
treatment
Carbohydrate-deficient transferrin >3.0%
 sensitivity and a specificity of 60 to 75 %
 With a biological half-life of approximately 16 days,
this test can also be useful in monitoring abstinence
in alcoholics.

Mean corpuscular volume >91.0 µm3

Uric acid >6.4 mg/dL for men, >5.0 mg/dL for women

SGOT/SGPT

HDL

 Biological markers should only be used as an adjunct

to other screening measures.
PARAMETER NORMAL ALCOHOL COMMENTS
ABUSE/DEPENDENCE

MCV(Mean 76-94 Increased Direct Toxic effect

Corpuscular cumm Indirect –megaloblastic
Volume) changes(B12,Folic acid
deficiency)

Gamma 0-50 IU/L Increased Indicates recent heavy

Glutamyl consumption/relapse.
Transferase False Positives-
(GGT) Anticonvulsants,
anticoagulants,OCPs
Others-nonalcoholic
liver
disease,hyperlipidemia,
hyperthyroidism
PARAMETER NORMAL ALCOHOL COMMENTS
ABUSE/
DEPENDENCE

SGOT,SGPT 0-40 IU/L Increased Hepatocellular injury ,

Elevation=severity of damage
SGOT:SGPT-2:1=ALD
<1=Nonalcoholic liver disease
>1=advanced chronic viral
hepatitis
Alkaline 35-135 IU/L Increased Less specific
Phosphatase GGT:ALP>1.4=suggests ALD
>3.5=Diagnostic

High Density 35- Increased Moderate consumption

Lipoproteins 70mg/dL
(HDL)

Prothrombin Elevated Decreased Clotting Factors

time
 Alcohol breath test
A reliable and inexpensive method for
assessing recent alcohol consumption.

 Venous blood levels should be obtained if

dangerously high levels of intoxication are
suspected, when a patient is comatose, or
for medical–legal purposes.

 BAC greater than 150 mg/dl in a patient

showing no signs of intoxication can be
interpreted to reflect physiological
tolerance.
 Brief interventions are typically of 5- 30 minutes
duration.
 Involve motivational interviewing and counseling
techniques.
 Usually targeted at individuals who are risky rather
than dependent drinkers.
 The aim is to alert the drinker that they are
drinking at levels that could lead to health
problems, and encourage them to reduce their
consumption to reduce the risk of future health
problems.
Through direct questioning during the
assessment interview.
1. “What would you be prepared to do to solve
this drinking problem?”
2. “How confident are you that you can achieve
this?”
3. “Are you prepared to attend the next
appointment?”
 Pre-contemplation: refusal to acknowledge
problems
 Contemplation: ambivalence about change.
MC
 Preparation: planning for change
 Action: the act of change
 Maintenance: maintaining the new behavior
 Feedback: Personal Feedback about the risks
associated with continued drinking, based on
current drinking patterns, problem indicators, and
health status.

 Responsibility: Emphasis on the individual’s

personal Responsibility and choice to reduce
drinking behavior.

 Advice: Clear Advice about the importance of

changing current drinking patterns.
 Menu: A Menu of alternative change options. This
emphasizes the individual’s choice to reduce
drinking patterns and allows them to choose the
approach best suited to their own situation.

 Empathy: from the person providing the

intervention is an important determinant of patient
motivation and change.

 Self-efficacy: involves instilling optimism in the

patient that his or her chosen goals can be
achieved.
 Group of procedures.
 Sobering up acutely intoxicated patients to
management of severe withdrawal symptoms.
 Prevents progress of early withdrawal symptoms to
life threatening complications.
 Relieve withdrawal symptoms.
 Opportunity to explore, assess, initiate
modification of medical, social, psychiatric and life
style problems.
Goals of detoxification
 Treatment of alcohol withdrawal symptoms
 Prevention of initial and recurrent seizures
 Prevention and treatment of delirium tremens
 Prevention of medical and psychiatric
complications of alcohol withdrawal
 Prevention of “kindling” effect
 Prevention of Wernicke-Korsakoff’s psychosis
 Improvement in likelihood of abstinence
Timeline from Alcohol withdrawal symptoms
last drink
Onset: 6 to 8 Generalised hyperactivity, tremor, sweating, nausea, retching,
hours mood fluctuation, tachycardia, increased respiration,
Peak: 10 to 30 hypertension and mild pyrexia(Shakes , Jitters)
hours
Subsides: 40
to 50 hours
Onset: 0 to 48 Withdrawal seizures(rum fits)
hours
Onset: 12 Auditory and visual hallucinations may develop that are
hours characteristically frightening(horrors)
Duration: 5 to
6 days
Onset: 48 to Delirium tremens: coarse tremor, agitation, fever, tachycardia ,
72 hours profound confusion, delusions and hallucinations
Clinical Institute Withdrawal Assessment for Alcohol
revised (CIWA-Ar)
 <=10 – mild withdrawal
 10-15 – moderate withdrawal
 >15 – severe withdrawal

Alcohol Withdrawal Symptoms - Rating Scale (AWS)

up to 4-mild withdrawal, 5-7 moderate withdrawal,
8-14 severe withdrawal and >15 very severe
withdrawal. Not a validated scale.
Short Alcohol Withdrawal Scale (SAWS)
 score total of 12 or above indicates the possible
need for medication to reduce alcohol withdrawal
symptoms.
 The SAWS requires further research and is
recommended for use with the standard clinical
assessment and nursing observations.
 BENZODIAZEPINES
• Benzodiazepines are the treatment of
choice for alcohol withdrawal.
• Mechanism of action-
1. Cross-Tolerance
2. Anti-convulsant properties

• Chlordiazepoxide commonly used- low

dependence forming potential
• Hepatic Impairment- short-acting
benzodiazepine treatment of choice.
AGENT ADVANTAGES DISADVANTAGES

Benzodiazepines Widely used Abuse potential

Long acting Rapid onset, Erratic IM

(Diazepam, prolonged action, absorption,
Chlordiazepoxide) more effect on Less safe - liver
anxiety and disease, confusion,
depression sedation

Shorter acting Less risk of over-

(Lorazepam, sedation, Increased risk of
Oxazepam) Better absorption seizures,
IM, Higher likelihood of
Preferable in liver dependence
failure, elderly
Drug Half Life Initial Average Maximum
Dose Dose/ Day Dose/Day

Chlordiazpoxide 24-48 25mg 50-100mg 250mg

hours

Diazepam 20-90 5mg 10-20mg 100mg

hours

Lorazepam 10-20 1mg 2-4mg 12mg

hours

Oxazepam 4-14 15mg 10-30mg 200mg

hours
• Withdrawal regimens:

1.Fixed Dose Reduction

2.Variable Dose Reduction

3.Front Loading
FIXED DOSE REGIMEN

• Community or non-specialist inpatient/

residential settings.

• Starting dose of chlordiazepoxide can be

estimated from current alcohol
consumption. ( 20 units- 20mg QID )

• Then 20% reduction daily

• Taper over 5-7 days

• Monitor on CIWA-Ar or SAWS

Moderate alcohol dependence: example of
a fixed dose chlordiazepoxide treatment
regimen
Time Dose Total daily
dose
Day 1 20 mg qds 80 mg

Day 2 15 mg qds 60 mg

Day 3 10 mg qds 40 mg

Day 4 5 mg qds 20 mg

Day 5 5 mg bd 10 mg
Severe alcohol dependence: example of a
fixed dose chlordiazepoxide regimen

Time Dose Total daily

dose (mg)

Day 1 40 mg qds + 200

40 mg prn
Day 2 40 mg qds 160
Day 3 30 mg qds 120
Day 4 25 mg qds 100
Day 5 20 mg qds 80
Day 6 15 mg qds 60
Day 7 10 mg qds 40
Day 8 10 mg qds 30
Day 9 5 mg qds 20
Day 10 10 mg nocte 10
 SYMPTOM-TRIGGERED REGIMEN
• Specialist alcohol inpatient or residential
settings.

• In patients without history of complications.

• Regular monitoring and severity

assessment- medication only when
withdrawal symptoms appear.

• chlordiazepoxide 20–30 mg hourly as

needed.
 FRONT LOADING REGIME
• Initial loading dose of medication, e.g.
chlordiazepoxide 100 mg, followed by further
doses of between 50 and 100 mg
approximately every 4–6 hours until light
sedation is achieved.

• Monitored every 2 hours :basic observations

and a withdrawal scale.

• C/I in advanced liver disease, COPD or

following a head injury.

• Use in well-monitored inpatient settings.

• Ciwa-ar score >15 or a SAWS score >12
during assisted withdrawal- further
intervention is required

• In hallucinations or agitation, an increased

dose of benzodiazepine should be
administered

• Liver cirrhosis and/or functional liver

impairment, chronic Respiratory disease –
Lorazepam/oxazepam preferred

• Withdrawal scale should be used as a marker

of optimal dosing
TREATING SOMATIC SYMPTOMS
1. Dehydration adequate fluid intake.

2. Pain Paracetamol

3. Nausea and vomiting Metoclopramide 10

mg or prochlorperazine 5 mg 4–6 hourly

4. Diarrhoea Diphenoxylate and atropine or

loperamide

5. Skin itching antihistamines

OTHER DRUGS
Supplementary vitamins
• Inpatient detoxification: parenteral thiamine –
prophylaxis against wernicke’s encephalopathy

• IM/IV ampules b-complex vitamins for 3-5

days

• Outpatient basis – oral thiamine 300 mg

minimum daily

• IM preparations less anaphylactic

 Acute intoxication is the result of alcohol entering
the bloodstream faster than it can be metabolized
by the liver.

 Reason for peaking of BAC – stopped

drinking/drinking at steady rate/imbibed large
quantity in short time

 Condition checked every ½ hrly

 Hospitalize- start rehydration.

If in coma, then
 Protect airway
 Toxicological screening of blood and urine
 Treat hypoglycaemia with 50 – 100 ml of 25%
dextrose solution and saline flush.
 Thiamine 100 mg iv/im to prevent Wernicke-
Korsakoff syndrome, which can cause a seizure.
 Apply hemodialysis if the blood alcohol
concentration is dangerously high (>400 mg/dL),
and especially if there is metabolic acidosis.
 If aggressive/violent patient, then
 Calm the patient,encourage to eat food
 Quiet comfortable environment
 Lorazepam 1-2 mg/Haloperidol 5-10 mg
orally/im/iv –Repeat if necessary
Medical Emergency
 < 5% of Alcohol Withdrawal syndrome
 Usually begins in 48-96hrs.
 Last for 1-5 days
 May be associated with seizure.
 In untreated cases mortality is up to 20%.

Triad of symptoms includes-

 - Clouding of consciousness,
 - Hallucinations and Illusions,
 - Marked tremors.
 Autonomic hyperactivity, dehydration, electrolyte
imbalance.
 Delusions may be present
 May lead to circulatory collapse, coma & death
 RISK FACTORS
1. Concomitant medical/surgical illness
2. Older age
3. Prior DT
4. Prior detoxification
5. Prior seizures
6. Time since last drink
7. Malnutrition
8. Severity of alcohol dependence
7. Elevated SGOT
8. Increased craving
9. Higher BAC
10. Long duration of alcohol dependence >6 years
 Treatment
 IV Fluid for hydration.

 Mainstay are BZDS-

 -Lorazepam 2mg or Diazepam 10mg iv.
 -Repeated doses till symptoms clear
 Doses should be tapered in 5-7days

 Thiamine 200-300mg IM daily for 3-5 days.

 Oral Thiamine 100 mg three times a day.

 Untreated non-alcohol related seizure disorder –

Phenytoin 15mg/kg
 Beta blockers if SBP>180 mmHg or Heart rate > 120/min
 5-15% cases of alcohol withdrawal

 Within 24-48hrs but may up to 7days

 Usually generalized and tonic-clonic character

 Usually one or two episodes

 30% of pts develop delirium

Management
 Obtain IV access for treatment
 Quick assessment of vitals, airway, consciousness
 History-r/o independent seizure disorder
 Physical Examination
 Confusion/somnolence beyond post-ictal period is
suggestive of drug toxicity/withdrawal delirium
 Basic biochemical tests-Electrolytes, Glucose,
Calcium, LFT, RFT
 LP
 CT brain
 EEG
Treatment
 Give iv diazepam until seizure activity ceases
 5-10mg iv initially, repeat if necessary every 15min up to
a maximum dose of 100mg
 Protracted single convulsion- Diazepam 2-5mg IV
bolus(max 20mg) OR Lorazepam 2-4mg(max 8 mg)
 Cluster Attack(3/more within 24 hrs)-standard doses of
Phenytoin(18mg/kg in 250-500ml NS at 40-50 mg/min)
 Thiamine 100 mg IV bolus- prevent Wernicke-Korsakoff’s
Syndrome.
 Neurologist opinion.
 Avoid anticonvulsant unless history of primary Seizure
disorder.
 Symptoms of anxiety, insomnia, and mild
autonomic overactivity are likely to continue for 2
to 6 months after the acute withdrawal has
disappeared.
 No pharmacological treatment for this syndrome
appears appropriate.
 It is possible that Acamprosate may work.
 It is important that the clinician warn the patient
and discuss cognitive and behavioral approaches
that might be appropriate to helping the patient
feel more comfortable.
 At least theoretically, these protracted withdrawal
symptoms may enhance the probability of relapse.
1)Hallucinations – occurs within 12 to 48hr after
last drink. It can be auditory, visual
(MC)(Lilliputian hallucinations), tactile
hallucinations.

• Addition of an antipsychotic (e.g. haloperidol 5–

10mg orally up to tds) should be considered if
BZD fails but cautiously due to risk of seizures
2) Alcoholic hallucinosis: It can be alcohol
induced or alcohol withdrawal psychotic
disorder.

 Main difference between alcoholic

hallucinosis and delirium tremens is that in
alcoholic hallucinosis the patient will be in
clear consciousness.
• Wernicke’s encephalopathy is a progressive
neurological condition caused by thiamine
deficiency.

• Ophthalmoplegia, ataxia and confusion

• TREATMENT:
 100mg BD or TDS for 1-2 weeks
 Chronic amnestic disorder that follows
wernicke’s encephalopathy.

 Cardinal features: irreversible damage,

impaired anterograde memory with
confabulations.

 Treatment: Thiamine 100mg BD or TDS for 3-

12 weeks.
 Might be a first-line alternative to
benzodiazepines.

 Carbamazepine appears to be effective throughout

the range of alcohol withdrawal symptoms,
including severe withdrawal, and is not contra-
indicated in liver failure.

 Meta-analyses: carbamazepine appeared as

efficacious as relatively low doses of oxazepam if
used in an approximately 7-day reducing regimen
in mild-to-moderate withdrawal.
Includes three major components:
(1) motivation enhancement - continued efforts to
increase and maintain high levels of motivation
for abstinence.
(2) lifestyle modification - work to help the patient
readjust to a lifestyle that maximizes functioning
and decreases the risk for drinking.
(3) Relapse prevention- treatment often requires
repeated presentations of materials to remind the
patient that abstinence is key, and to help
optimize support systems and healthy coping
styles.
 Causes for relapse :
◦ People – peer persuasion-direct/indirect
◦ Places/Occasions – Bars/Festivals
◦ Emotions – Positive/Negative
◦ Thoughts – Craving/Self challenging
Non-pharmacological interventions
Drawing on data from systematic reviews &
meta-analyses effective treatments are:

 Motivational enhancement
 Social skills training
 Cognitive behavioral approaches
 Behavioral marital therapy
 Among patients attending specialized clinics
the proportion who can sustain problem free
drinking is small- 5%
 Abstinence is better
 No safe drinking limits
 RCT doesn’t favor controlled drinking
 Enhancing motivation has a place not only at
onset but throughout the clinical contact.

 Motivation enhancement=CBT=AA

 RCT: Motivation enhancement>traditional

supportive therapy

 Patients forced into treatment have medium-

term outcomes similar to those who attend
voluntarily.
 Build a trusting relationship in which the
client and the clinician cooperate in planning
and implementing the intervention.

 Reduce the client’s fear and distrust of

treatment programs and thereby encourage
the client to continue attending treatment
and follow-up appointments.

 Provide a non-threatening and supportive

environment in which the client can address
sensitive issues.
 It is not expected that counselling alone is
sufficient to change the drinking behavior of
most clients.

 Rather, the goal of counselling is to develop

a relationship between the clinician and the
client, which supports implementing specific
strategies designed to combat the drinking
problem.
Millner & Rodnick (1991)
 “A client-centred, directive method for
enhancing intrinsic motivation to change by
exploring and resolving ambivalence”

 Motivational interviewing is viewed as a

method of communication rather than a set
of techniques, or a specific strategy.
General processes: CEA
 Collaboration. Counselling involves a
partnership that honors the client’s
experiences and perspectives. The counselor
provides an atmosphere that is conducive
rather than force to change.
 Evocation. The resources and motivation for
change are presumed to reside within the
client. Intrinsic motivation for change is
enhanced by drawing on the client’s own
perceptions, goals and values.
 Autonomy. The counselor affirms the client’s
right and capacity for self-direction and
facilitates informed choice.
Guiding principles: DRES
 Express empathy

 Develop discrepancy-Change is motivated by

a perceived discrepancy between present
behaviour and important personal goals or
values

 Roll with resistance

 Support self-efficacy
 Motivational interviewing is a moderately
effective stand-alone treatment intervention
which helps to reduce alcohol intake and to
improve psychosocial outcomes.

 Motivational interviewing can be delivered as

a treatment prelude to increase motivation to
change.
Cognitive behavioral interventions encompass
a range of strategies and techniques including-
 skills training,
 behavioral self-management,
 cognitive restructuring,
 cue exposure and
 behavioral couples therapy
Cognitive behavioral interventions aim to give
the client a set of thinking and behaving
strategies that can be used to change
problematic behaviors.
Skills training
 It involves teaching people social skills that
might help them function without the use of
alcohol.

 There is consistent evidence that skills

training helps to reduce alcohol consumption
in both the short term and the long term
among risky drinkers and alcohol dependent
persons.
In skills training an emphasis is placed on
ensuring that clients:

 Learn to listen and to communicate

effectively with others
 Give and receive compliments and criticism
 Learn to refuse unwanted requests
 Learn to communicate non-verbally and
verbally
 Begin to build a social support network
Problem solving skills training
Goals:

 Recognize when a problem exists

 Generate a variety of possible solutions
 Select the most appropriate option
 Generate a plan for action
 Evaluate the effectiveness of the selected
approach
Behavioral self-management training involves a
series of strategies such as:

 Self-monitoring
 Setting drinking limits
 Controlling rates of drinking
 Identifying problem drinking situations
 Self-reward for limited drinking
 One potential problem arising from this
procedure is that drinkers for whom
abstinence is advisable may see this strategy
as a means of “safe” drinking.

 If there is doubt about a client’s ability to

deal with this information appropriately, it is
recommended that the technique not be
used.

 If used in the context of a goal of abstinence,

it should be presented as a strategy to cope
with a temporary lapse to drinking.
Cognitive restructuring
 The goals of cognitive restructuring are for
clients to recognize when they are thinking in
a way that is likely to lead to drinking and to
interrupt and challenge these thoughts.
 Cognitive restructuring is appropriate for
clients with a goal of either moderation or
abstinence.
 Effective if there is comorbid anxiety or
depression.
Cue exposure
 Based on the associative learning principle,
 Assumes that people, places and events that
regularly precede drinking become associated with
the pleasant effects of alcohol, and alcohol
consumption becomes a conditioned response to
these cues.

 Classical learning models, the client only needs to

be exposed to alcohol repeatedly without being
allowed to drink in order to prevent the usual
drinking response to those cues.
 Social learning theory models assume that the
chance to practise coping skills in the presence of
alcohol cues is important in reducing relapse.
Couples and family therapy
 There is scant research on the effectiveness
of family therapy in the area of alcohol and
substance abuse.

 Evidence that marital/relationship problems

precede heavy alcohol use is limited, but
relationship problems have been associated
with relapse after treatment.

 Good family support predicts better outcome.

Behavioral marital therapy (BMT) is a particular type
of behavioral couples therapy on which much of
the research examining behavioral couples therapy
has been based.
O’Farrel & colleagues
-A behavioural contract between the alcohol
dependent person and the partner to maintain
disulfiram ingestion.

 Alcohol-Focused Spouse Involvement which

rearranges reinforcement contingencies in the
family to decrease family member behaviors that
trigger or enable drinking and to increase positive
reinforcement for sobriety.
 AA is an international self-help organisation founded in
USA by two alcoholic men- Dr. Bob Smith(surgeon) & Bill
Wilson(a stockbroker) in 1935.
 Alcoholism is viewed by AA as a physical, psychological &
spiritual illness which can be arrested but not cured.
 12 steps
 The use of prescribed medication is not formally
disapproved of by AA.
 Its is only an adjunct to formal treatment.
 Members attend group meetings, usually twice weekly on
long-term basis.
 In crisis, immediate relief can be obtained from other
members by telephone.
FDA APPROVED DRUGS OTHERS

1. Disulfiram -1951 1. Ca channel antagonist –

2. Naltrexone-1994 Gabapentin,Pregabalin
3. Acamprosate-2004 2. Ondansetron – 5HT3
4. Naltrexone extended release antagonist
injectable-2006 3. SSRIs – 5HT reuptake
inhibitor
4. Buspirone – 5HT1A partial
agonist
5. Baclofen – GABA-B agonist
6. Topiramate – GABA agonist
 1ST approved drug by FDA – 1951
 MOA – Inhibits Aldehyde Dehydrogenase resulting in
accumulation of acetaldehyde
 “Disulfiram-alcohol reaction” – Headache, Flushing,
Blurred vision, giddiness, nausea and vomiting,
hypotension, thirst.
 Thus acts as Aversive Rx discouraging impulsive alcohol
use.
 Severe reactions - optic neuritis, peripheral neuropathy,
fatal hepatitis, cardiovascular collapse.
 Side effects
◦ Drowsiness(45%)
◦ Reduced memory(40%)
◦ Headache(35%)
◦ Itching , decreased sleep , dizziness
 Avoid alcohol containing preparations – cough
syrups, tonics, lotions, perfumes, local preps.
 Contraindications - hepatic failure, psychosis,
severe MI, CVA , pregnant women , seizure
disorder, children, unwilling patients.
 Dosage – Tabs of 250 mg, 125-500mg/day
 Morning dose convenient
 Duration : 6 mths - 2 years, atleast 1 yr
 Patient warned about 24 hr abstinence before
drug intake.
 Disulfiram reactions can occur upto 2 weeks after
last dose.
 Useful in well motivated, stable persons.
 Opioid antagonist – blocks the reinforcing and rewarding
effects of alcohol.
 Reduced Craving (anti-craving) and reduced rate of relapse
 S/E- nausea, constipation, anxiety, fatigue
 C/I - in pt. taking opioids, withdrawal phase, hepatic failure
 Dose- 50mg daily
Naltrexone depot implants -380 mg implanted im –approved
2006
Who to give?
 Patients who are moderately to severely alcohol dependent,
medically stable, and who are not currently using opioids, may
be suitable candidates.
 High craving
 Adverse effects: GI disturbance, hepatic impairment,
dysphoria, nausea, headeache, dizziness,
constipation,abdominal pain
 LFT regularly monitored
 Duration: 3-12 months
 Calcium acetyl homotaurinate
 Decreases the glutamenergic excitatory activity (NMDA)
& Increases GABA activity.
 Supresses the urge to drink
 Abstinence rates appear to be Doubled
 S/E – diarrhoea, skin rashes, decreased libido, anxiety,
depression
 C/I – severe hepatic impairment, pregnancy, lactation,
severe renal impairment.
 Dose- >60 kg- 333mg 2-2-2 before meal , <60 kg-
333mg 2-1-1 (as food interferes with absorption)
 When to start?: as soon as detox is complete (2-7 days
after last drink)
 Duration:The usual treatment period is 3-6 months
 Serotonergic dysfunction has been implicated in
the neurobiology of alcohol misuse and
dependence
 In heavy social drinkers, citalopram (40 mg/day)
and fluoxetine (60 mg/day) have been shown to
improve some drinking outcomes over a short
period
 In the absence of depression or anxiety, there is
limited evidence and one review stated that their
use could not be recommended.
 Both are useful in treating alcohol
dependence because they have anticonvulsant
and anxiolytic properties.

 They bind to calcium channels and reduce

calcium currents resulting in reduced activity.

 In relapse prevention, gabapentin has been

shown to increase time taken to restart heavy
drinking and reduce alcohol craving.

 A small open study showed people who

misused alcohol and were given pregabalin
remained abstinent longer than those
given naltrexone (Martinotti et al , 2008)
 5HT3 antagonist.

 It reduce dopaminergic activity, which results in

reduced alcohol drinking.

 Ondansetron, has been studied and clinical efficacy

has been shown for some doses, more so in early-
onset alcoholism (Johnson et al., 2000).

 Dosage : 4 microgram/kg body wt BD
 GABA-B agonist
 In 2012, Baclofen was approved for use in
the treatment of alcoholism
 Shown to enhance abstinence, reduce
drinking quantity, reduce craving, and
reduce anxiety in alcohol-dependent
individuals.

 Dose- 5-20 mg BD
 Enhances GABA and reduces glutaminergic activity

 Decrease in no. of drinking days, no. of drinks

/day, increased abstinence rates (Alcohol &
Alcoholism 2011)

 Better outcomes in early part of 12 week trial

 Dosage : Start at 25mg, titrate slowly to 300mg OD

to avoid S/E like paraesthesia, anorexia, cognitive
deficits, renal calculi.
 5HT1A receptor agonist.

 Meta-analysis of studies –Malec et al,’96 showed

efficacy is secondary to its anxiolytic effects than
on drinking behaviour.

 Initial Dose: 7.5 mg BD

 Maintenence Dose: 5 mg BD/TDS

Type 1
• Sertraline
• Acamprosate

Type 2
• Ondansetron
• Naltrexone
• Baclofen
 ADS+NDS: Bupropion.

 ADS+ODS/ cocaine dependence : Naltrexone.

 ADS+ BZD dependence: single BZD

 ADS + BPAD: Naltrexone > Acamprosate > Disulfiram,

avoid Lithium

 ADS + Depressive disorders: SSRIs- Sertraline

 ADS + Anxiety: SSRIs, Baclofen, Acamprosate.

 ADS+Liver disease: Acamprosate.

 ADS+ Renal disease: Naltrexone.

 NICE –never drink during pregnancy especially 1st 3
months
 If withdrawal symptoms present, pharmacological
cover on inpatient basis offered
 Risk-benefit assessment to be done
 Timing of detoxification risk-assessed against
continued alcohol consumption
 Chlordiazepoxide-low risk but dose related
malformations observed.
 Have comparatively short histories of heavy
drinking.
 Rarity of physiological dependence on alcohol and
alcohol-related medical complications.
 Motor vehicle accidents, homicide, and suicide
 Values and behavior of the peer group
 Assess family interactions, internalizing &
externalizing disorders.
 No drugs approved for relapse prevention in
<18yrs
 Interventions need to be concrete & goal-oriented
Elderly

 untreated medical illness

 prescription drug abuse
 drug interactions
 psychiatric comorbidity
 cognitive impairment
 functional assessment
 need for social services
 no difference in outcome following Rx
 For a person meeting criteria of both harmful use
and dependence, the diagnosis of DEPENDENCE
should be made.

 Repeated detoxifications can produce ‘Kindling

effect’, so even mild withdrawal should be
treated aggressively to prevent the increased
severity of subsequent withdrawal episodes.

 In alcohol withdrawal seizures, avoid

anticonvulsants unless there is H/O primary
seizure disorder. (mainstay of t/t here is iv
diazepam)
 In untreated DT mortality is upto 20%, so
must be diagnosed and promptly treated.

 DOC for alcohol withdrawal is BZD

(chlordiazepoxide or diazepam).

 Disulfiram- should be prescribed in motivated

pt. only after explaining its s/e.
THANK YOU