1. ALCOHOL – EFFECTS,
DEPENDENCE,
WITHDRAWAL &
TREATMENT
St Vincent’s Hospital D&A Service
Lisa Jayne Ferguson and Jeku Jacob

2. Alcohol
 CNS depressant: acting at several sites in brain
Enhances GABA activity
Stimulates serotonin receptor = pleasure & nausea
Stimulates dopamine and opioid receptors = euphoria
& reinforcement
 Provides kilojoules or energy but NO nutritional value
 Is a toxin to multiple organs

3. Alcohol
1 standard drink (10 gm) raises the
BAL by approximately 0.02
The body/liver processes 1 standard
drink (10 gm) per hour
BAL continues to rise for 30 – 90
minutes after the last drink

4. The National Health & Medical Research Council 2009
Recommended maximum: (1/100 lifetime chance of death)
 Women: 2 standard drinks/day
 Men: 2 standard drinks/day (was 4)
Risky: ie increasing life time risk of death
 Women: 3 standard drinks/day
 Men: 5 standard drinks/day
Known to cause harm: - chronic organ damage
 Women: Over 4 standard drinks/day
 Men: Over 6 standard drinks/day
 Pregnant women recommends 0 drinks – data still sparse
 Health benefits of Alcohol greatly exaggerated

5. Alcohol Dependence
 More common than dependence on all other drugs
combined in Australia
 About 5% of Australians are dependent
 17 times as common as opioid dependence
 10% receive some form of treatment
 Only 1% are prescribed anti-craving drugs ...this is
compared to -30% opioid dependent people in treatment
 Alcohol contributes to over 3,000 deaths per year and
50,000 hospitalisations

6. Alcohol Intoxication
0.01-0.02
Sense of well being
0.02-0.05
Slightly dizzy, talkative, over-confident, euphoria,
clumsy
0.06-0.1
Decrease inhibitions & motor co-ordination. Increase
pulse, ataxia, talkative
0.2-0.3
Poor judgement, nausea, vomiting
0.3-0.4
Blackout, memory loss, emotionally labile
0.4+
Stupor, breathing reflex threatened, deep anaesthesia,
death (in non tolerant people)

7. High Alcohol Consumption – Long Term
Effects
 GIT/Hepatic




Alcoholic Hepatitis
Cirrhosis
Pancreatitis
Colitis
 Nervous System
 Endocrine
 Hypgoglycemia (don’t give
thiamine until you replace sugar)
 Hypogonadism
 Oncology
 Increased risk of mouth, colon,
breast and larynx
 Wernicke/Korsakoff’s
 Alcoholic Dementia
 Myopathy
 Obstetric
 Neuropathy
 Hematologic
 Cardiac
 AF
 Hypertension
 Cardiomyopathy
 Foetal Alcohol Syndrom
 Bone marrow suppression leads
to macrocytic anemia
 Cirrhosis can lead to
thrombocytopenia

8. Alcohol Related
Presentations to ED

9. Common Presentations
 Pt can usually come in complaining of withdrawal symptoms.
 Hallucinations
 Tremors
 Sweats
 Anxiety
 Perceptual disturbances
 Seizures
 Hemetemesis
 Abdominal Pain
 Falls
 Palpitations
 Productive Cough
 Jaundice
 Feeling unwell
 Intoxication
 Trauma/ Violence

10. History taking
 Please take a good history
 Try to quantify alcohol use to grams/SD
 How often they drink (try to take a day history)
 Last drink?
 Age of starting drinking
 Reasons why drinking was exacerbated
 ?Depression/Suicidality
 Social Situation
 Any other substances of misuse
 Please exclude other causes of presentation

11. Physical Findings
 Signs of Chronic Liver Disease
 In withdrawal
Anxious
Sweaty
Tachycardic and Hypertensive
Tremulous
 Wernicke’s: confused, ataxic and opthalmoplegic
 Malnourished
 Encephalopathic if CLD

12. Investigations









UDS
BAC
BSL
FBC – may show macrocytic Anemia
UEC, LFTS, CMP
B12 + folate – usually deficient
INR - caogulopathy
CT brain if history of fall/seizures or ataxic
U/S abdomen if you suspect CLD

13. Management
Hydrate
Thiamine (BEFORE GLUCOSE) – youll
never go wrong with giving more
300 mg tds iv please to start on all intoxicated
pts
500 mg tds iv if you suspect wernicke’s
Glucose in thiamine deficiency precipitates
wernicke’s
Replace Sugar please if glycopenic
Replace Electrolytes

14. Alcohol Withdrawal
Is a syndrome of central nervous system hyperactivity
Onset
 Usually between 6-24 hours after last regular dose of
alcohol (symptoms occur as blood alcohol concentration
decreases)
Duration
 Between 2-7 days (most commonly 4-5 days)
 Residual symptoms will last longer when brain injury is
involved

15. Rationale
 Withdrawal symptoms can range from mildly
uncomfortable to life threatening
 Symptoms can be prevented or alleviated
 Early intervention can reduce or prevent progression to
severe withdrawal, injury, dehydration or seizures

17. Severe Alcohol Withdrawal
Symptoms
CAN BE FATAL (RARELY)
Seizures - 6-48 hours
Mod-Severe Hypertension - 6-48 hours+
(Diastolic above 110)
Disorientation - 48 hrs+
Confusion - 48 hrs+
Hallucinations - 48 hrs+
Delirium Tremens- 48 hrs+

18. Alcohol Withdrawal Scales
 The most systematic & useful way to measure
the severity of withdrawal is to use a
withdrawal scale
 These provide a baseline against which changes
in withdrawal severity may be measured over
time
 Research shows that the use of scales minimises
both under-dosing & overdosing with
benzodiazepines for alcohol withdrawal
syndromes

19. AWS
 Please do not start AWS prematurely
 Calculate when BAC will return to normal, then start
 (Pt’s may go into withdrawal prior to this – clinical
perogative necessary)
 AWS not diagnostic...make diagnosis of withdrawal first
before instituting
 5 – 10 mg every 4 hours with a cap of 80 mg in the first
24 hours
 Can get 120 mg in first 24 hours if appropriate

20. Perceptual disturbances/
Hallucinations in withdrawal
Curtains/floor/furniture moving
‘Insects over skin’
Hallucinations rarer and signify severity of
withdrawal
colour changes
Animal forms
Scary
These require antipsychotics
Olanzapine

21. Special Considerations
Use Oxazepam (7.5-45mg) if:
Cirrhosis
Be careful with doses of BZD
Elderly
Head injury
Stay away from BZD if delerious, use
antipsychotics instead
Difficulty in encepholapathy  use
lactulose!

22. Gorman House
 Pts in ED who don’t require admission can be
rehydrated, given thiamine and discharged
 Gorman House is appropriate for detoxification
 Gorman House – 5/7 program
 Pts need to be discharged on weaning diazepam
 Day 1 – 10mg qid
 Day 2 – 10 mg tds
 Day 3 – 10 mg bd
 Day 4 – 10 mg daily

23. Wernicke-Korsakoff Syndrome
 Form of brain injury resulting from thiamine
deficiency
 If not treated early it can lead to permanent brain
damage & memory loss
 Signs & symptoms of Wernicke’s encephalopathy
(usually the first stage of the syndrome) =
1. Ophthalmoplegia (reduced eye movements) or
Nystagmus (dancing eyes)
2. Ataxia
3. Confusion

24. Wernicke-Korsakoff Syndrome
 This condition is reversible if recognised and treated
with parenteral vitamin B1
 Parenteral thiamine should be administered before
any form of glucose
 Glucose in the presence of thiamine deficiency risks
precipitating Wernicke’s encephalopathy
 Korsakoff’s by itself : confabulation, amnesia and apathy
 (ask: ‘do you remember me?’ Or ‘where did we meet
before’

25. Wernicke-Korsakoff Syndrome
 NB: Studies have shown that the absorption of PO
thiamine in alcohol dependent patients is minimal to
none!!!
 Example of dosing regime:
 Thiamine 300mg tds IVI / IMI for 3/7’s , then PO
 If WE established: Thiamine dose should be increased

26. Potential Problems
 High doses of Diazepam should not be used to treat
alcohol related delirium
 Diazepam can precipitate and cause delirium
 Olanzapine/Haloperidol can lower seizure threshold
 AWS should only be used for Alcohol, not opioid or
benzodiazepine withdrawal

27. Treatment Options for Patients
 Follow up with outpatient services / Tx –
- 1:1 counselling (public & private),
- Groups (SMART Recovery, AA’s)
- Residential Rehab,
- Pharmacotherapy‘s
* Impaired Cognition (Moderate-Severe)
1. Cognistat /Neuropsych Assessment
2. Guardianship /Inebriates Act
3. Placement?????

28. Take Home Messages
Take a good alcohol history
Don’t start the AWS too early
Please replace thiamine iv before glucose
(at least one dose)
 AWS not diagnostic – pt not improving,
consider alternative diagnosis

29. SVH A&D Service
THANK YOU 