ALCOHOL BASICS

PROF.DR .ELANGOVAN S UNIT

D.SUBBURAJ

EPIDEMIOLOGY
MC substance abuse in INDIA -ALCOHOL
NEXT MC- CANNABIS

South india prevalance -33 55% Highest alcohol consumption -- KERALA

8 L / CAPITA

WORLD WIDE LUXEMBOURG (15.5 L)

ALCOHOL
1 unit=10gm=12.5 ml absolute alcohol=1 drink Can t be stored in the body Energy -7 kcal gm Some amount of other nutrients
some potassium ; no sodium Riboflavin & niacin Possible antioxidant benefits from polyphenols(?) sometimes VIT C

STANDARD DRINK
any drink that contains about 14gm Of absolute alcohol
AUSTRIA U k AUSTRLIA FINLAND CANADA U S JAPAN 6 gm 8 gm 10 gm 11 gm 13.6 gm 14 gm 19.75 gm

STANDARD DRINK

Beer 4 8 %

Gin 40.0 - 48.5

Vodkas 40.0 - 50.0

Wines 7 22 %

Rum 40.0 - 95.0

Whiskies 40.0 - 75.0

Brandies 40.0 - 43.0

BINGE DRINK
U S DEFINITION
Consumption of five or more standard drink by males , four or more by females in about 2 hrs

U K DEFINITION
Drinking more than twice the daily limit (>8 men, >6 women)

NIAAA DEFINITION
Any time one reaches a peak BAC of 0.08% or higher

SAFE DRINK
no uniform guidelines UK 2-3 standard drink daily or 14 per week USA 1 standard drink daily or 7 per week Not more than 3 drinks on any one occasion Don t drive or engage in hazardous activities Don t drink if an interacting drug has been taken

Where does Alcohol come from?

Grain whisky and beer Potatoes vodka Grapes wine and brandy

Apples cider Honey mead Sugar rum

COCK TAIL
DRINK
1 glass stout 1 glass beer (250 ml) (250 ml)

KJ
570 380 280 280 250 440 5

1 Glass white wine (100 ml) 1 Glass red wine (280 ml)

1 Nip of spirit 40% (30 ml ) 1 Glass mixer (440 ml)

1 Glass diet mixer (250 ml)

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Graph source: National Institue on Alcohol Abuse and Alcoholism

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Factors that influence absorption

Gender
Women produce less of enzyme needed to breakdown alcohol Women have greater fat content and alcohol is not fat soluble so it enters the blood stream faster Women have less water so alcohol does not become diluted Women absorb more alcohol during the premenstrual phase

 Absorption increased by
Rapid gastric emptying ( carbonated beverages) Absence of meal Absence of congener Dilution

Tissue distribution - blood flow & water content Obese persons & women- higher BAC Follows zero order kinetics So metabolism doesn t vary widely in the population

3-pathways of EtOH metabolism

ADH in stomach (males) ADH & MEOS in liver (males & females)

Catalase in liver (males & females) MEOS- microsomal ethanol oxidizing system -CYP2E1

ETHANOL

CATALASE

ADH ACETALDEHYDE

MEOS

ALDH
MITOCHONDRIA ACETATE

EXTRA HEPATIC TISSUES

Microsomal Ethanol Oxidizing System (MEOS)

Alternate pathway used, in addition to ADH, when alcohol intake is excessive End products include:
Ethanol acetaldehyde NADPH + H+ NADP+ No ATP formation = Energy Wasteful

Also involved in drug metabolism

Excess ethanol- less MEOS for drug- drug overdosage

Genetic Variation

50% of Asians have inactive ALDH Develop flushing reaction Acetaldehyde Dehydrogenase (ALDH) varies in Caucasians, Blacks and Asians. poly morphism TNF PROMOTER - susceptible to alcoholic steatohepatitis Alcoholism -inherited ; specific gene not identified

Metabolic effects
High NADH/NAD RATIO
Prevents pyruvate entering in to gluconeogenesis- HYPOGLYCEMIA Converts pyruvate to lactate - acidosisuricacidaemia- GOUT Increase TG - FATTY LIVER

INDUCES DRUG METABOLISM FREE RADICAL FORMATION ACCUMALATION OF ACETALDEHYDE

POSSIBLE HEPATO TOXIC EFFECTS OF ACETALDEHYDE

Increase lipid peroxidation Binds plasma membrane Interferes with mitochondrial electron transport chain Inhibits nuclear repair Interferes with microtubule formation Activates complement Increases collagen synthesis

DRUG INTERACTIONS
Synergies with anxiolytics, antidepressants, antihistamines, hypnotics, opioids-- marked CNS depression with motor impairment -- chances of accidents increase Insulin & sulfonylureas: enhances hypoglycaemia Aspirin & other NSAID gastric bleeding Parcetamol toxicity Acute alcohol ingestion inhibits , chronic alcoholism enhances phenytoin metabolism

Disulfiram like reaction

irreversible ALDH inhibitor- acetaldehyde accumulates flushing reaction

DIAGNOSIS OF ALCOLISM
TOLERANCE
A state of adaptation in which increasing amounts of alcohol are needed to produce desired effects

PHYSICAL DEPENDENCE
A typical withdrawal syn appears on interruption of drinking , which is relieved by alcohol itself or other drugs

IMPAIRED CONTROL
Total alcohol intake cannot invariably be regulated , once drinking has begun at any drinking occasion

CRAVING
A dysphoria of abstinence that leads to relapse

Causes of Alcoholism
Genetics
Strong family link 50% of fathers, sons, brothers of alcoholics are likely to become alcoholics Children of alcoholics are more then 3-4 times more likely to become alcoholics

Personality types
Low self esteem Chronic anxiety Antisocial personalities

QUESTONNAIRES
CAGE ( cut down , annoyed ,guilty, eyeopener) MAST (michigan alcoholism screening test) AUDIT ( alcohol use disorder identification test) RAPS4 (rapid alcohol problems screen 4) QFS ( quantity frequency score)

CAGE QUESTIONARE
Have you ever felt to cut down? Have people annoyed you by criticizing ? Have you ever felt guilty or bad ? Have you ever had a drink first thing in the morning to steady your nerves or to get ride of hang over? (eye opener)

One yes suspicion More than one-alcohol abuse or dependance

CLINICAL COURSE
Age at first drink Age at first intoxication Age at first problem Age at onset of dependence Age at death 13 15 yrs 15 17 yrs 16 22 yrs 23---40 yrs 60 yrs

Spontaneous remission in 20% Same as general population.

DSM-IV CRITERIAS
ALCOHOL ABUSE Recurrent use of alcohol associated with any one of the following with in 12mns
1. 2. 3. 4. Failure to fulfill major role at work Physically hazardous Related legal problems Despite of having persistent social problems

ALCOHOL DEPENDENCE
Any one of following in 12 mns Increased amount of alcohol needed to achieve desired effect & continued use of same amount Withdrawal symptoms Persistent desire to cut down Important social /recreational activities given up Increased time spent to obtain/to use /to recover from the effects alcohol

Collection of blood for alcohol

Spirit - not used to clean skin Preservative sod fluoride(100mg)+potassium oxalate(30 mg) Refrigerated, should not be freezed WIDMARK FORMULA
Wt of alcohol(gm) in body= BWT X BAC X 0.6 (men) 0.5(women)

Breath analysis
Alcohol absorbs infra red rays Amount of infra red rays absorbed is proportional to alcohol contents 60 100ml of air is receieved in a plastic balloon End portion of forced expiration gives correct results Conc in exhaled air is about 0.05% of blood content

thank you