1. Alcohol & Amphetamines
John R. Martinelli
MSIII, SGUSOM
Bergen Regional Medical Center
Department of Psychiatry

2. Alcohol

3. Statistics (WHO)
• Globally: 6%
• N. America, Europe, Japan, Australia: 7%
• Eastern Europe and Central Asia: 12%
• UK: 1 in 3 patients = 33%

4. 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)

5. 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

6. 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

7. Etiology
• Early Onset
– Genetic Predisposition
• Late Onset
– Psychosocial Factors

8. 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

9. 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

10. 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

11. 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

12. Wernicke-Korsakoff Syndrome
Thiamine (B1) Deficiency (PDH complex)
• Confusion
• Memory
• Ataxia
• Nystagmus
• Ophthalmoplegia

13. Fetal Alcohol Syndrome
• Most severe
• Characteristic faces
• Growth retardation
• CNS involvement
• Cognitive impairment
• Learning disabilities
• Behavioral

14. 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

15. Methamphetamines
“Crystal Meth”
“ICE”

16. 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)

17. Pathophysiology
• CNS stimulant
• Catecholamine reuptake inhibitor
• MAOI
• Blocks presynaptic vesicular storage
• IV/IM peak plasma levels @ 30 minutes
• PO peak @ 2-3 hours

18. 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

19. Signs & Symptoms
• Cardiovascular
– Chest pain, aortic dissection, MI
– Palpitations, tachyarrhythmia
– Dyspnea and edema
– Hypertension
• Respiratory
– Dyspnea
– Wheezing
– Pneumothorax

20. Signs & Symptoms
• Gastrointestinal
– Abdominal pain
– Obstruction
• Renal
– ATN
• Skin
– Delusional parasitosis
– Cellulitis, abscess, necrosis

21. Signs & Symptoms
• Dental Caries
– Peridental abscess
– METH Mouth

22. Diagnosis
• Clinical Signs & Symptoms
– History
– R/O medical condition
– Urine toxicology

23. Treatment
• Toxicity/Overdose
– ABC’s
– PEG if toxic oral ingestion
– Charcoal if suspect contaminants
– Correction of
hypertension, hypotension, hyperthermia, metabo
lic and electrolyte abnormalities
– Control severe psychiatric agitation (Haloperidol
vs Atypicals, Benzo’s, Labetalol)

24. Treatment
• Difficult to remove patient from subculture
• Detox not associated with decreased abuse
• Residential rehabilitation slight efficacy

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