2. "... alcohol has existed longer than all
human memory. It has outlived
generations, nations and ages. It is a
part of us, and that is fortunate indeed.
For although alcohol will always be the
master of some, for most of us it will
continue to be the servant of man" Director
of the National Institute on Alcohol Abuse and Alcoholism(Chafetz,
1965, p. 223).

3. Historical Aspects
 One of the most commonly used chemical
substances for intoxication by humans in
history.
 Word 'alcohol' originates from the Arabian
term 'al-kuhul', meaning "the kohl" a powder
for the eyes, which later came to mean
"finely divided spirit".

4. ..history
 No one knows when beverage alcohol was
first used
 The discovery of late Stone Age beer jugs
has established the fact that intentionally
fermented beverages existed at least as
early as 10,000 B.C.(Patrick, 1952, pp. 12-13).
 In INDIA alcoholic beverages appeared in
between 3000 BC - 2000 BC.

5. EPIDEMIOLOGY
 According to a study conducted by the NIMHANS for the
WHO, published in 2006, nearly 30% of adult men and
<5% of women consume alcohol.
 Male to female ratio of 6:1
 Age- Men in their late teens or early 20s are heaviest
drinkers.
 Occupation- more in chefs, barmen, executives, actors,
Doctors etc( as they have easy access to alcohol)
 Average age of initiation has reduced from 28 years
during the 80s to 20 years in recent years.
 Alcohol-dependent person decreases his life span by 10
to 15 years.

6. all
Overall prevalence~ 30%

7. Overall prevalence<5%

8. Alcohol content of different beverages
 Expressed as `UNIT‟. 1unit=8grams of
alcohol.
BEVERAGE ALCOHOL UNITS OF
CONTENT(%) ALCOHOL
Ordinary Beer 3% 2 per pint
Strong Beer 5.5% 4 per pint
Extra strong Beer 7% 5 per pint
Table wine 8-10% 7 per bottle
Fortified wines 13-16% 15 per bottle
(sherry, pot, vermouth)
Spirits(whisky, gin, 32% 30 per bottle
brandy, vodka)

9. Risk of social and health
problems
ALCOHOL INTAKE RISK OF PROBLEMS
(units/week)
MEN 0-21 LOW
WOMEN 0-14
MEN 22-50 INCREASING, particularly in
WOMEN 15-35 smokers
MEN > 50 HIGH, particularly in smokers
WOMEN > 35

10. ETIOLOGY
 Various theories to explain alcoholism-
1. Psychological theories
2. Psychodyanamic theories
3. Behavioral theories
4. Sociocultural theories
5. Genetic theories
6. Childhood history

11. ETIOLOGY
Psychological Theories
 Alcohol reduces tension, increase feelings of power,
decrease the effect of psychological pain
 Alcohol decreases nervousness, increased feeling
of well being, help them to cope with day to day
stresses of life.
Psychodynamic Theories
 Due to anxiety lowering effects of alcohol, people
may use this to help them deal with self-punitive
harsh superegoes and to decrease unconscious
stress levels.
 Fixation at oral stage of development may also
explain use of alcohol to relieve frustations by
taking the substance by mouth.

12. Behavioral Theories
 Expectations about the rewarding effects of
alcohol, and subsequent reinforcement after
alcohol intake all contribute to decision to drink
again after first drink..
Sociocultural Theories
 Cultural attitudes toward drinking, and personal
responsibilities for consequences are important
contributors to alcohol use..
Childhood history
 Childhood history of ADHD, conduct disorder,
antisocial personality disorder increases a child‟s
risk for an alcohol related disorder as an adult..

13. Genetic Theories
 Close family members have a fourfold
increased risk.
 The identical twin of an alcoholic person is at
higher risk than is a fraternal twin.
 Adopted-away children of alcoholic people
have a fourfold increased risk.

14. EFFECTS OF ALCOHOL ON BODY
1) Absorption- 10% from stomach,
90%-small intestine(proximal).
2) Peak blood conc.- In 30-90 minutes.
3) Metabolism- 90% in liver
(by ADH and ALDH enzymes)
-10% ex unchanged by kidney
and lungs
 Body can metabolises ¾ ounce(1 ounce=28.35 gms)
of 40%spirits in 1 hour.

15. Causes Histamine Toxic
release
ACETALDEHYDE
Disulfiram
reaction.
ALCOHOL ALDH
Non- toxic
ACETIC ACID

16. …EFFECT OF ALCOHOL ON BODY
EFFECT ON BRAIN
(Pathophysiology)-
 Dopamine increase in limbic system- pleasure
(alcohol acutely increase dopamine levels in brain)
 Serotonin- related to amount of intake
 GABAA receptors
 NMDA receptors

21. …EFFECT OF ALCOHOL ON BODY
1) EFFECT ON SLEEP-
- decreased sleep latency, but
- decrease in REM and NREM stage 4
- more sleep fragmentation, and longer episodes of
awakening
(thus overall harmful effect on sleep)
2) TOLERANCE-
With repeated administration of alcohol, larger and larger
doses are required to produce the desired effect.
3) CRAVING-
The state of motivation to seek out alcohol.

22. 4) BLACKOUTS-
Blackout indicates a memory impairment
(anterograde amnesia) for the period when the
person was drinking heavily and was awake
5)PERIPHERAL NEUROPATHY
- tingling and numbness in hands & feet
- develops in about 10% alcoholics
6) CEREBELLAR DEGENERATION
7) CENTRAL PONTINE MYELINOSIS(present as
quadriplegia, lethargy, and cognitive impairment )
8) MARCHIAFAVA- BIGNAMI SYNDROME(thinning of
the corpus callosum along with a change in
consciousness, ataxia, and possible dementia)

23. 9) Pathological intoxication (mania a potu)-
- An extraordinary severe response to small
amounts of alcohol
- marked by apparently senseless violent
behaviour, usually followed by sleep, exhaustion
& „amnesia‟ for the episode.

24. GIT-
- Gatritis, fatty liver, alcoholic cirrhosis, pancreatitis.
CVS-
- Hypertension and increased risk of Stroke.
(Paradoxically, moderate drinkers i.e. about 7-10 units/week have
lower risk of coronary artery disease than non-drinkers!!)
FETAL ALCOHOL SYNDROME-
- seen in about 5% children born to heavy-drinker
mothers.
-severe mental retardation, microcephaly, facial
defects, asd etc.
-even fetal death, and spontaneous abortion.

25. ICD-10-
F10--F19 Mental and behavioural disorders
due to psychoactive substance use
 F10. -Alcohol
 F11.-Opioids
 F12.-Cannabinoids
 F13.- Sedatives or hypnotics
 F14.-Cocaine
 F15.-Other stimulants, including caffeine
 F16.-Hallucinogens
 F17. -Tobacco
 F18.-Volatile solvents
 F19.-Multiple drug use and use of other
psychoactive substances

26. CLASSIFICATION OF ALCOHOL-RELATED
DISORDERS
ICD-10 DSM-IV
1. F10.0 Intoxication 1. Intoxication
2. F10.1 Harmful use 2. Abuse
3. F10.2 Dependence syndrome 3. Dependence
4. F10.3 Withdrawal state 4. Withdrawal
5. F10.4 Withdrawal state with 5. Withdrawal delirium
delirium 6. Psychotic disorders
6. F10.5 Psychotic disorders 7. Mood disorders
7. F10.6 Amnestic syndrome 8. Anxiety disorders
8. F10.7 Residual and late 9. Amnestic disorders
onset psychotic disorder 10. Dementia
9. F10.8 Other mental and 11. Sexual dysfunction
behavioral disorders
12. Sleep disorders

27. F10.0 ACUTE INTOXICATION
A transient syndrome
-due to recent substance ingestion
-that produces clinically significant psychological
and physical impairment.
 Changes are reversible upon elimination of
substance from the body.
 Legal definition of intoxication in USA is alcohol
conc. > 80-100 mg/dl of blood.

28. LEVEL LIKELY IMPAIRMENT
 20-30 mg/dl  Slowed motor performance,
decreased thinking ability.
 30-80 mg/dl  Increase in motor & cognitive
problems.
 80-200 mg/dl  Increase in incoordination and
judgement errors.
Lability of mood, Cognitive
deterioration
 200-300 mg/dl  Marked slurring of speech,
Nystagmus, Blackouts.
 >300 mg/dl  Impirement in vital signs,
possibly Death!.

29. F10.1 ALCOHOL HARMFUL USE
 A pattern of psychoactive substance use
-that is causing damage to health,
-the damage may be physical or mental.
Diagnostic guidelines
 Actual damage to physical or mental health.
 Acute intoxication itself is not a sufficient evidence of the
damage to health.
 Harmful use should NOT be diagnosed if dependence
syndrome, a psychotic disorder (F10.5), or another specific
form of alcohol-related disorder is present.

30. F10.2 DEPENDENCE SYNDROME
 A cluster of physiological, behavioural, and
cognitive phenomena
-in which the use of a substance takes on a
much higher priority for an individual than
other behaviours that once had greater
value.

31. Diagnostic guidelines for dependence
syndrome-
Three or more of the following is necessary to
diagnosis in previous year.
a) Strong desire.
b) Progressive neglect of alternative pleasures or interests.
c) Evidence of tolerance.
d) Signs of withdrawal on attempted abstinence
e) Loss of control of consumption.
f) Continued drug use despite negative consequences.

32. Five-character codes for dependence
 F10.20 Currently abstinent
 F10.21 Currently abstinent, but in a protected environment
 F10.22 Currently on a clinically supervised maintenance or
replacement regime [controlled dependence]
 F10.23 Currently abstinent, but receiving treatment with
aversive or blocking drugs (e.g. naltrexone or disulfiram)
 F10.24 Currently using the substance [active dependence]
 F10.25 Continuous use
 F10.26 Episodic use [dipsomania]

33. Subtypes of Alcohol Dependence
Type A alcohol dependence
 Late onset
 Few childhood risk factors
 Mild dependence (with few alcohol related
problems and little psychopathology)
Type B alcohol dependence
 Early onset
 Many childhood risk factors
 Severe dependence( with a strong family history
and much psychopathology)

34. Some more subtypes….
Gamma alcohol dependence
 Represents alc. Dep. In those who are active in
Alcoholic Anonyms.
 These persons are unable to stop drinking once
they start, but if drinking is terminated (due to ill
health or lack of money), they can abstain quite
well..
Delta alcohol dependence
 Include those who must drink a certain amount
each day, but are unaware of a lack of control

35. Difference b/w harmful use and
dependence-
 For a person meeting criteria of both harmful use
and dependence, the diagnosis of
DEPENDENCE should be made.
 Tolerance and Withdrawal state are features of
DEPENDENCE.
 Harmful use should NOT be diagnosed if
dependence syndrome, a psychotic disorder
(F10.5), or another specific form of alcohol-related
disorder is present.

36. F10.3 ALCOHOL WITHDRAWAL
“A group of symptoms and signs which occur on
cessation or reduction of use of a psychoactive
substance,
-that has been taken repeatedly, usually for a
prolonged period and/ or in high doses.”
 It can be-
 Uncomplicated- ocurring in 6-48 hrs and abates
after 2-5 days.
 Complicted- with seizures, delirum.

37. Diagnosis of alc. withdrawal
A) Cessation of (or reduction in) alcohol use.
B) Two (or more) of the following, developing within
several hours to a few days after Criterion A:
(1) Autonomic hyperactivity
(2) Increased hand tremor
(3) Insomnia
(4) Nausea or vomiting
(5) Transient hallucinations or illusions
(6) Psychomotor agitation
(7) Anxiety
(8) Grand mal seizures
C) Social & occupational functioning impairment.
D) Not due to a general medical condition or mental
disorder.

38. S/S ALCOHOL WITHDRAWAL SYNDROME
Time withdrawal symptoms
6 to 12 hours Insomnia, tremulousness, mild anxiety,
gastrointestinal upset, headache, diaphoresis,
palpitations, anorexia
12 to 24 hours Alcoholic hallucinosis: visual, auditory, or tactile
hallucinations
24 to 48 hours Withdrawal seizures: generalized tonic-clonic
seizures
48 to 72 hours Alcohol withdrawal delirium (delirium tremens):
hallucinations (predominately visual), disorientation,
tachycardia, hypertension, low-grade fever,
agitation, diaphoresis

39. ALCOHOL WITHDRAWAL SEIZURES
 5-15% cases of alcohol withdrawal
 Within 24-48hrs but may up to 7days
 Tonic-clonic in nature
 Usually one or two episodes
 30% of pts develop delirium
 Give IV diazepam until seizure activity ceases
 5-10mg IV initially, repeat if necessary every 15min up
to a maximum dose of 100mg
 Call to neurologist
 Avoid anticonvulsant unless history of primary SD

40. F10.4 DELIRIUM TREMENS
 Medical Emergency
 < 5% of Alcohol Withdrawal syndrome
 Usually begins in 48-96hrs.
 Last for 1-5 days
 May be associated with seizure(F10.41)
 In untreated cases mortality is up to 20%.
 Triad of symptoms includes-
- Clouding of consciousness,
- Hallucinations and Illusions,
- Marked tremors.
 Autonomic hyperactivity, dehydration, electrolyte imbalance.
 Delusions may be present
 May lead to circulatory collapse, coma & death

41. Management of Delirium tremens
 IV Fluid for hydration.
 Mainstay are BZDS-
-Lorazepam 2mg or Diazepam 10mg IV/IM.
-Repeated doses till symptoms clear
-Doses should be tapered in 5-7days
 Thiamine 200-300mg IM daily for 3-5 days.
Oral Thiamine three times a day.
 Monitor vitals 4hrly
 Closely observe for focal neurological deficit
 Pt should be on high calorie, high carbohydrate diet.

42. F10.5 PSYCHOTIC DISORDERS
 Occur during or immediately after alcohol use and are
characterized by-
.Vivid hallucinations (mainly auditory),
.Delusions or ideas of reference(morbid jealosy),
.Psychomotor disturbances (excitement or stupor),
.Abnormal affect.
 Sensorium is usually clear but some clouding of
consciousness may be present.
 The disorder typically resolves in 1-6 months.

43. Diagnostic guidelines..
 A psychotic disorder occurring during or
immediately after drug use (usually within 48
hours)
- provided that it is not a manifestation of
withdrawal state with delirium and
- should NOT be of late onset.
 Late-onset psychotic disorders (with onset more
than 2 weeks after substance use) should be
coded as F10.75.

44.  The diagnosis of psychotic state may be further
specified by the following five character codes:
1. F10.50 Schizophrenia-like
2. F10.51 Predominantly delusional
3. F10.52 Predominantly hallucinatory (includes alcoholic hallucinosis)
4. F10.53 Predominantly polymorphic
5. F10.54 Predominantly depressive symptoms
6. F10.55 Predominantly manic symptoms
7. F10.56 Mixed

45. F10.6 AMNESTIC SYNDROMES
 A syndrome associated with
 chronic prominent impairment of RECENT memory;
 remote memory is sometimes impaired,
 while immediate recall is preserved.
 Diagnostic guidelines-
1. Impairment of RECENT memory(learning of new material) ;
Disturbance of time sense.
2. Preserved immediate recall;
3. Preserved consciousness; and absence of generalised
cognitive impairment.
4. Evidence of chronic (high-dose) use of alcohol.
 Includes:- Wernicke’s encephalopathy, &
Korsakov’s syndrome.

46. WERNICKE ENCEPHALOPATHY
 Acute onset
 Completely reversible G.O.A.
 Global confusion
 Opthalmoplegia - Horizontal nystagmus, 6th n. palsy
 Ataxia, Vestibular dysfunction
 Rapidly reversible with large parenteral doses 200-
300mg of Thiamine. Then 100mg orally BD or TDS
for 1-2 wk.
 In pts. receiving iv fluids, include 100mg of thiamine
in each liter of iv glucose solution.

47. KORSAKOFF’S SYNDROME
 Chronic condition
 Reversible in only 20% of cases
 Impaired Recent memory and anterograde amnesia in an
alert and responsive pt.
 Confabulation +/-
 In most cases, the level of recent memory loss is out
of proportion to the global level of cognitive impairment.
 Thiamine100mg orally BD or TDS for 3 to 12 months.

48. F10.7 RESIDUAL & LATE ONSET
PSYCHOTIC DISORDER
 A disorder in which alcohol-induced changes of
cognition, affect, personality, or behaviour persist
beyond the period during which a direct alcohol-
related effect might be assumed to be operating.
 Further subdivided by the following five-character
codes:-
 F10.70 Flashbacks
 F10.71 Personality or behaviour disorder
 F10.72 Residual affective disorder
 F10.73 Dementia
 F10.74 Other persisting cognitive impairment
 F10.75 Late-onset psychotic disorder

49. F10.8 Other mental and behavioural
disorders
 Code here any other disorder in which the
use of a substance can be identified as
contributing directly to the condition, but
which does not meet the criteria for inclusion
in any of the above disorders.

50. ALCOHOL INDUCED PERSISTING
DEMENTIA
 Global decreases in intellectual functioning, cognitive
abilities, and memory.
 But recent memory difficulties are consistent with the
global cognitive impairment.
(an observation that distinguishes the syndrome from
alcohol-induced persisting amnestic disorder.)
 50-70% show increased size of the brain ventricles and
atrophy of frontal lobe.
(these changes appear to be partially or completely
reversible.)
 Brain functioning improves with abstinence,
but 1/2 of all affected patients have long-term and even
permanent memory and thinking disabilities.

51. ALCOHOL INDUCED ANXIETY
DISORDERS
 Only two anxiety disorders may be more closely
tied to alcoholism: panic disorder & social
phobia.
 During the first 4 to 6 weeks of abstinence
 Disappear with time alone.

52. ALCOHOL INDUCED SEXUAL
DYSFUNCTION
 Alcohol in small doses appears to enhance
sexual receptivity in women and increase
arousal to erotic stimuli in men.
 Heavy continued drinking may cause significant
sexual impairment:-
- impaired desire
- impaired arousal
- impaired orgasm
- sexual pain.
 Symptoms usually subside after 3-4 weeks of
alcohol abstinence.

53. MANAGEMENT
Management of-
1) Alcohol Intoxication
2) Dependence & Withdrawal
3) With specific co-morbid conditions.

54. Mx of Alcohol intoxication
 Check for vital signs- blood pressure
- respiratory depression
- arrhythmias
 Any signs of Hypoglycemia, Hepatic failure
 If very aggressive- low dose lorazepam
(1mg orally) or
-antipsychotic(5mg Haloperidol)
 Ensure hydration (iv fluids)
 Symptomatic and supportive treatment.

55. Mx of Dependence
Step 1) Detection of alcohol dependence
Step 2)Intervention
Step 3) Detoxification
(or withdrawal from alcohol)
Step 4) Relapse prevention
(or maitenence of abstinence)
& Rehabilitation.

56. The Moral and Medical models
Moral model-
 Public drunkenness should be punished.
 Little evidence that it influences the behavior of
excessive drinkers!
Medical model-
 Jellinek in 1960- “The disease concept of
alcoholism”.
 Instead of blame and punishment, Medical
treatment is provided to excessive drinkers.

57. (A) DETECTION OF ALCOHOL
MISUSE
By-
1- Screening
2- History taking
3- Laboratory diagnosis
SCREENING-
1. CAGE questionnaire
2. AUDIT questionnaire

58. CAGE Questionnaire
 Consist of 4 questions-
1) Have you ever felt to Cut down on your
drinking?
2) Have people Annoyed you by criticizing your
drinking?
3) Have you ever felt Guilty about your drinking?
4) Have you ever had a morning drink (Eye
opener) to get rid of hangover?
-> 2 or more yes= alcohol misuse.
-> Overall sensitivity is Good but modest
specifity.

59. AUDIT questionnaire
 Ten questions.
 Designed at the request of WHO.
 Scores are given for each answer.
Score Intervention
 8-15 - brief intervention based on
risk factors.
 16-19 - brief intervention, regular
monitoring.
 20-40 - diagnostic assessment,
detoxification, and other
treatments.

60. DRINKING HISTORY
 Describe a typical day‟s drinking. What time you take first
drink of the day?
 When did daily drinking start?
 Any withdrawal symptoms in morning or after abstinence?
 Previous attempts at treatment?
 Medical complications?
 Patient‟s attitude towards drinking?

61. LABORATORY DIAGNOSIS
Parameter Normal value Value in chronic
alcoholics
Serum level of γ- Men 4-25 U/L >30 U/L
glutamyl transferase Women 7-40 U/L
(GGT)
Mean corpuscular 80-98μm3 >100 µm3
volume(MCV)
Carbohydrate-deficient <60mg/l >1.3% of total transferrin
transferrin concentration
AST & ALT <45 U/L AST:ALT, 2:1
Blood Alcohol conc.- if a person is not intoxicated even when blood alc.
Levels are high, he is likely to be unusually tolerant to alcohol.

62. (B) INTERVENTION
 Goal is “to increase motivation” for treatment & continued
abstinence
Motivational interviewing
-Aim is to persuade pt. to engage in treatment programme.
-Express empathy
-Avoid arguing, let the pt.say
and then “roll with” resistance
-usually multiple sessions are required to persuade the pt.
 In the meantime- Family may benefit from counselling or
referral to self help groups like-
AL-Anon(for spouses of excessive drinkers) &
AL-Ateen(for their teenage children)
 Also pt.can be encouraged to meet people recovering
from alcohol, through AA(Alcohol Anonymous)

63. (C) DETOXIFICATION
 i.e Withdrawal of patient from alcohol.
 Step 1) Thorough Physical examination
(e.g. liver failure, gi bleed, arrhythmia, glucose or electrolyte
imbalance; any combined drug abuse)
 Step 2) Rest & Adequate nutrition
(Vit-B complex specially Thiamine)
 Step 3) BZD & other symptomatic pharmacotherapy

64. Pharmacotherapy
1) Benzodiazepines-
 -drug of choice
 -decreases s/s of withdrawal & prevents seizures & DT
also
 -long acting(chlordiazepoxide,diazepam) are preferred
 -Dose:- 20-30mg Chlordiazepoxide
6 hourly on day1
or 5-10mg Diazepam.
(dose up to 250mg on day1 can be given in severe
withdrawal)
 - then decrease gradually and stop in 5-7 days.
(dose can be adjusted depending on s/s)
 Oxazepam/Lorazepam/Temazepam for elderly or hepatic
impairment pts.

65. Common benzodiazepines used to treat
patients with alcohol withdrawal Syndrome
Drug Half Life Initial Dose Average Maximum
Dose/ Day Dose/Day
Chlordiaze- 24-48 hours 25mg 50-100mg 250mg
poxide
Diazepam 20-90 hours 5mg 10-20mg 100mg
Lorazepam 10-20 hours 1mg 2-4mg 12mg
Oxazepam 4-14 hours 15mg 10-30mg 200mg

66. …pharmacotherapy
2) Thiamine & Magnesium
 Prevention & treatment of Wernicke‟s enceph &
Korsakoff‟s psychosis.
 No impact on s/s of withdrawal or seizures or DT.
 Thiamine- 100 to 300mg im or orally daily.
for at least 7 days
(..upto 1-2 wk in WE & upto 3-12 months in KP )
 Thiamine should always precede glucose
administration

67. …pharmacotherapy
 Magnesium-
 HypoMagnesemia occurs in withdrawal
 Mg is required for normal utilization of Thiamine also!
 In severe case deficiency is 1-2 meq/kg body wt.
 Correct half of deficit on day1, then remaining on
following 4 days
 Dose- 30-45 meq(4 to 6 ampules) of mag.sulphate in 2
litre of iv fluid on day1
 Half of above dose Daily for 4 days

68. …pharmacotherapy
OTHER DRUGS& ADJUNCTIVE THERAPIES
Sympatholytics-
-decreases autonomic hyperactivity in withdrawal.
-Clonidine(α2 agonist)- can cause postural
hypotension
-Propanolol(β-blocker)- increases incidence of
delirium
Barbiturates(Phenobarbital)
-for withdrawal in pregnant women
-lack of sufficient evidence

69. …pharmacotherapy
Neuroleptics-
-Reduces symptoms of withdrawal(agitation &
hallucinations)
-Haloperidol & Phenothiazines- but increases risk of
seizures.
Carbamazepine-
-can reduce minor s/s of withdrawal
-no special benefit

70. (D)MAINTAINING ABSTINENCE
& REHABILITAION
Pharmacological Psychosocial
Rx interventions
1. Disulfiram 1. Brief interventions
2. Acamprosate 2. Extended
3. Naltrexone interventions
4. Others 3. Group therapy
-SSRI 4. Family therapy
-Topiramate 5. Self-Help
-Ondansetron groups(Alcohol
Anonymous)
-Baclofen

71. Disulfiram
 Inhibits Aldehyde dehydogenase(ALDH), so acetaldehyde
accumulates
 Flushing, weakness, nausea, tachycardia on taking alcohol
 Thus acts as aversive Rx discouraging impulsive alcohol use
 Before starting disulfiram pt. should be abstinent from alcohol for
12 hours
 Disulfiram reactions can occur upto 2 weeks after last dose
 No tolerance with continous Rx of disulfiram
 Dose-800mg on day1 then100-250mg daily
 C/I – heart failure, CAD, HTN, pregnancy, psychosis
 High risk of serious S/E so generally not preferred

72. Acamprosate
 Calcium acetyl homotaurinate
 Decreases the glutamenergic excitatory activity (NMDA)
& Increases GABA activity.
 Supresses the urge to drink
 Abstinence rates appear to be Doubled
 S/E – diarrhoea, skin rashes, decreased libido, anxiety,
depression
 C/I – severe renal impairment (eliminated completely by
kidney)
 Dose- 333mg 2TDS before meal (as food interferes with
absorption)

73. Naltexone
 Opioid antagonist – blocks the reinforcing and
rewarding effects of alcohol.
 Reduced Craving(anti-craving) and reduced rate of
relapse
 S/E- nausea, constipation, anxiety, fatigue
 C/I - in pt. taking opioids, hepatic failure
 Dose- 50mg daily

74. BACLOFEN
 GABA-B agonist
 Primarily used for the treatment of spastic
movement disorders.
 In 2012, Baclofen was approved for use in the
treatment of alcoholism
 Shown to enhance abstinence, reduce drinking
quantity, reduce craving, and reduce anxiety in alcohol-
dependent individuals.
 Dose- 30mg/day

75. Antidepressants
 Useful in pt. who experience persistent symptoms
of major depression after detoxification.
 May reduce drinking even in non-depressed
subjects.
 Only SSRIs are recommended
 SSRIs may improve drinking outcome in Type 1
but may worsen outcome in Type 2 dependence.

76. Alcohol Anonymous
 AA is an international self-help organisation founded in
USA by two alcoholic men- Dr. Bob Smith(surgeon)
& Bill Wilson(a stockbroker) in 1935.
 AA says “its primary purpose is to stay sober and help
other alcoholics achieve sobriety”
 Members attend group meetings, usually twice weekly
on long-term basis.
 In crisis, immediate relief can be obtained from other
members by telephone.

77. Treatment of specific co-morbid
conditions
1) Alcoholism with depressive symptoms-
- increased risk for relapse
- psychosocial Rx like Group therapy
2) Alcoholism with major depression-
- SSRI(fluoxetine, tianeptine) may be started
- TCA(due to sympathetic s/e) are not used
3) Alcoholism with dysthymic disorder-
- frequent relapses are common
- cognitive behaviour therapy may be considered

78. 4) Alcoholism with Anxiety-
- for mild anxiety symptoms, Rx is deferred till pt. is
abstinent for 2 wks
- In pt. who experience anxiety disorder separately
from any problem related to alcohol– anxiolytics
(long acting BZD) can be started.
- Buspirone (bcoz of no evidence of its interaction
with alcohol) can be used.

79. Take Home Message…
 For a person meeting criteria of both harmful
use and dependence, the diagnosis of
DEPENDENCE should be made.
 Repeated detoxifications can produce
„Kindling effect‟, so even mild withdrawal
should be treated aggressively to prevent the
increased severity of subsequent withdrawal
episodes.

80.  In alcohol withdrawal seizures, avoid anticonvulsants
unless there is H/O primary seizure disorder.
(mainstay of t/t here is iv diazepam)
 In untreated DT mortality is upto 20%, so must be
diagnosed and promptly treated.
 In Amnestic syndrome- Recent memory is impaired
with ABSENCE of generalised cognitive impairment
(presence of generalised cognitive impairment
suggest dementia)

81.  Mainstay of t/t for amnestic syndr is Thiamine.
(but has no role in t/t of withdrawal symptoms)
 Magnesium should be included in t/t for alcohol
dependence.
 DOC for alcohol withdrawal is BZD (chlordiazepoxide
or diazepam).
 Disulfiram- should be prescribed in motivated pt. only
after explaining its s/e.