1. Alcohol
Dr Alison Battersby

2. Alcohol has a short half life
“I am not a heavy
drinker. I can sometimes go
for hours without touching
a drop”

3. 10% of the population drink half the alcohol

4. Those pesky neurotransmitters
Significant actions on GABA and glutamate, primary neurotransmitters
Enhances GABA-A receptor function cf BDZ (sedation, relaxation, unsteadiness, amnesia)
High doses mimics barbiturate effect (locks open the channel, coma, respiratory depression)

5. And more…
Alcohol blocks glutamate NMDA-type receptors causing decreased excitation, sedation, amnesia, coma and death
Chronic use, NMDA receptors increase in number creating a hyperexcitable withdrawal state. Acamprosate may reduce this

6. Alcohol withdrawal
Compensatory glutamate receptor up-regulation with loss of magnesium leading to excess brain stimulation
Long term potentiation in the hippocampus is attenuated by alcohol

7. Acamprosate
Withdrawal increases in severity over time. Repeated withdrawal leads to greater glutamate levels and increased mortality. Blocked by acamprosate
Dahchour and De Witte

8. Alcohol and amines
Alcohol, as opiates, stimulants and cannabis release dopamine in brain, ? A common pleasure circuit
Low 5HT function leads to alcohol abuse and chronic use decreases 5HT, SSRIs may reverse this (middle-aged women)
Chronic alcohol damages brain noradrenaline system, leading to dementia

9. Alcohol and endorphins
Brain endorphins system is main site of action of heroin and other opiates. Alcohol releases endorphins this may explain therapeutic effect of naltrexone to reduce relapse and effect in Sinclair method

10. It only takes me one
drink to get me drunk.
The trouble is, I can’t
remember if it’s the
thirteenth or fourteenth!

11. Why drink alcohol?
Positive reward or reinforcement: pleasure. Escapism, euphoria, rush
Negative reinforcement: feel normal, anxiolytic, overcome withdrawal
Urge compulsion: cannot control use

12. Alcohol alters perception of self leading to decreased social anxiety

13. Alcohol and its withdrawal drives motivation
I would kill everyone in this room for a drop of sweet beer

14. Blood alcohol Detects recent drinking only, ethanol metabolised at
10g/hour
Breath levels correlate
closely with blood
In a person smelling of
alcohol BAC can confirm
recent drinking, suggest
tolerance if high BAC
low impairment
Urine alcohol longer
window of detection

15. GGT (gammaglutamyltransferase)
Most sensitive blood test that is widely available but only positive in 30% of heavy drinkers in community
Alcohol is the commonest cause of elevation but up to 50% GGT elevations for other reasons eg obesity, medications
Half life 2 weeks
Prognostic value, tool in monitoring

16. Other markers Aminotransferases AST:ALT ›1.5 suggests alcohol
MCV: slow to return to normal, T1/2 60days, non-specific eg nutritional, drugs, liver disease

17. Alcohol:management of withdrawal and detoxification
Where and when to detoxify?
What are the medical risks?
What setting is appropriate?
What does the service user want from detox?
How to integrate into the bigger treatment picture?

18. Treatment regimens:alcohol detox
Benzodiazepines are efficacious in reducing signs and symptoms of withdrawal and are recommended as the treatment of choice
No particular one except lorazepam or oxazepam in liver failure
Reducing regimen, front loading, symptom triggered

19. Surprise!
Carbamazepine has been shown to be efficacious and can be chosen as an alternative to benzodiazepines
Chlormethiazole is reserved for inpatient settings only after due consideration, risk of respiratory depression with alcohol

20. Seizures
Benzodiazepines, particularly diazepam reduces de novo seizures and are recommended for the treatment of withdrawal
No advantage in anticonvulsants and benzodiazepines combined
To prevent a second seizure in same withdrawal episode the evidence supports the use of lorazepam but does not support the use of phenytoin

21. Delirium Benzodiazepines, particularly those with
longer half life prevent
delirium and are
recommended
A cautionary tale!

22. Acamprosate
Increases abstinence rates by double to ≤ 40% after 3, 6 or 12 months
Start during detoxification Neuroprotective
If drink alcohol, less frequent and lower amount

23. Other medications
Naltrexone
Baclofen
Disulfiram
Odansetron …..

25. 1930s, Blauwe (or Blue) Week

26. Blessed is he who does not drink wine: Russia 1900