Chapter 53. Substance abuse
Alcohol dependence
Of the UK population, 2% suffer from alcohol dependence syndrome at any time.
Dependence is most common in:
• Those aged 40–54 years
• The divorced and separated
• Those who have never been married
• Publicans, doctors, journalists and senior businessmen are most vulnerable.
Factors increasing risk of dependence include:
• Cheap or easily available alcohol
• Unsupervised work routine
• Unsociable working hours
• Work involving separation from family or other stabilising social constraints.
Effects of alcohol
Psychological effects of alcohol
• Hallucinations of voices (alcoholic hallucinosis), which are usually derogatory in content, may occur in clear consciousness
• Depressive symptoms occur in 90% of people with alcoholism and there is a 10–15% risk of completed suicide associated with alcoholism
• Pathological jealousy manifests as a morbid delusional belief that a partner is being unfaithful and may put the partner at risk of serious violence.
• Liver damage
• Alcoholic hepatitis
• Fatty liver
• Cirrhosis
• Liver failure and hepatic encephalopathy
• Oesophagitis and gastritis causing vomiting and retching
• Mallory–Weiss tear in lower oesophagus causing haematemesis
• Portal hypertension causing oesophageal varices and possible massive haematemesis
• Peptic ulceration
• Acute and chronic pancreatitis (acute has a mortality of 10–40%)
• Carcinoma of upper gastrointestinal tract.
• Cardiac arrhythmias
• Cardiomyopathy
• Coronary artery disease
• Hypertension
• Cerebrovascular accident.
Metabolic
• Hypoglycaemia
• Ketoacidosis.
Haematological
• Anaemia
• Thrombocytopenia.
• Diffuse brain damage from cortical shrinkage and ventricular dilation
• Alcoholic dementia
• Wernicke–Korsakoff syndrome
• Seizures from alcohol withdrawal.
Wernicke–Korsakoff syndrome is caused by deficiency of thiamine (vitamin B1).
In acute Wernicke’s encephalopathy, symptoms include alteration in level of consciousness, nystagmus, external ophthalmoplegia, ataxia and peripheral neuropathy.
Alcoholics are frequently prescribed oral thiamine and given IV thiamine preparations in hospital.
Medical emergencies specifically related to alcohol
Acute intoxication
Acute intoxication may lead to physical injury from trauma or head injury and predisposes to hypoglycaemia.
Alcohol alone should never be accepted as a cause of reduced or lost consciousness
Acute alcohol withdrawal
Acute alcohol withdrawal occurs in the dependent state and is characterised by:
• Nausea
• Vomiting
• Tremors
• Excessive sweating
• Tachycardia.
It may begin within 6 hours of cessation or reduction of alcohol and peaks by 48 hours, subsiding over the next 7 days. It can be associated with withdrawal grand mal epileptic seizures 12–24 hours after drinking.
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