Substance Abuse: CNS Depressants - Alcohol
Alcoholism is a health problem surpassed only by heart disease and cancer. About one-third of adult patients in hospitals have problems related to alcohol and about 240,000 deaths a year are directly linked to alcohol abuse; an average of one in 10 deaths in the United States.
1. Liver-- With chronic, heavy ingestion of alcohol, metabolization of fat by the liver is decreased and normal storage and use of fats for energy is disrupted. As the fat accumulates, it is deposited in the liver, causing a reversible disease called hepatic steatosis (fatty liver). This common condition, characterized by nausea, vomiting, hepatomegaly, right upper quadrant pain and tenderness should resolve within two weeks of abstinence.
A more serious disease is alcoholic hepatitis (10-30% mortality) which may occur along with fatty liver and cirrhosis. Its symptoms include nausea, vomiting, hepatomegaly, right upper quadrant pain and tenderness, fever and chills. Laboratory tests and liver biopsy are used to distinguished fatty liver from mild hepatitis. Half of the individuals with alcoholic hepatitis who continue to drink develop cirrhosis.
The main feature of cirrhosis is progressive destruction of liver cells accompanied by regeneration and infiltration of the liver with connective (scar) tissue due to continued excessive drinking. The risk of developing cirrhosis has been estimated to increase with the daily consumption of 20g (9g equals 3/4oz. of ETOH) of alcohol in females and 40g in males. Once the scar tissue of cirrhosis develops, the liver is irreversibly damaged. Life-threatening complications of cirrhosis include gastric or esophageal varices, ascites, renal failure, and encephalopathy.
Serious hepatotoxicity can develop in chronic alcoholics who are taking therapeutic doses of acetaminophen. They usually seek help after jaundice and liver disease have already developed. Often the blood acetaminophen level is low and unmeasurable and the diagnosis is based largely on the aspartate amino-transferase level, prothrombin time, and a history.
2. Gastrointestinal Problems-- Alcohol can damage the lining of the esophagus, stomach, and small intestine by irritating the mucosa and causing inflammation. Alcohol increases the secretion of gastric acid and it combines with other irritants such as aspirin to cause bleeding. Alcoholics may mask nausea and pain associated with GI irritation by drinking. However, in cases of severe alcoholism, more serious gastric erosion can develop. As heavy drinking continues, the entire digestive system is irritated starting with the mucous membranes of the mouth and esophagus. Alcohol stimulates the production and release of acid even while it delays emptying of the stomach. Because of disturbances in the gastric-mucosal barrier and the presence of excess acid, most patients will have gastritis. Those who chronically ingest alcohol also have gastric ulcers. Upper gastric hemorrhage is also common due to ingestion of alcohol alone, or alcohol and aspirin.
A serious cycle is now in place because the gastritis from heavy drinking decreases the patient's appetite, leading to malnutrition. Even people who are eating a fairly good diet may be affected by worsening gastritis and eventually become malnourished. With the breakdown of the liver accompanied by vitamin deficiency and poor nutritional status, the chronic heavy drinker becomes extremely susceptible to infections and other types of disease. This pattern of systemic malnutrition and toxicity is a hallmark of alcoholism.
3. Pancreas-- Research shows that 40-95% of patients who develop pancreatitis are chronic, heavy drinkers. Alcohol modifies the pancreatic enzymes releasing proteolytic enzymes that damage the pancreas. In advanced stages, when little pancreatic tissue is left, diabetes mellitus and malabsorption can occur. The mortality of severe pancreatitis with complications may exceed 30%. Stopping the use of alcohol may decrease the pancreatic pain, but does not stop the progression of pancreatic dysfunction.
4. Cardiovascular-- The chronic, heavy use of alcohol is associated with hypertension, vascular abnormalities, cardiomegaly and cardiac arrhythmias. The atrial fibrillation which is so commonly observed after a high alcohol intake is called holiday heart syndrome.
5. Endocrine-- Hyponatremia, hypokalemia, hypoglycemia, diabetic symptoms, and abnormal thyroid tests may result from the chronic heavy use of alcohol.
6. Immune System-- Alcohol depresses the movement of white blood cells into areas of inflammation, thereby decreasing resistance to infection. Alcoholics are less resistant than the general population to tuberculosis (TB) and to infections and abscesses resulting from organisms such as Staphylococcus, Pneumococcus, Streptococcus, Hemophilus influenzae, Klebsiella pneumoniae, and Legionella pneumophila. Burns are more likely to result with complications, and the hospital stay may be longer. Respiratory herpesvirus infections may occur in patients who are chronic alcoholics with liver disease.
7. Musculoskeletal System-- Alcoholics have an increased risk of developing osteoporosis and osteonecrosis (metabolic bone diseases). They also risk developing chronic alcoholic myopathy (rhabdomyolysis) which causes pain and swelling in the large muscle groups, or if alcoholic polyneuropathy is also present, they may experience a painless, progressive muscle wasting.
8. Kidneys-- Alcohol is a diuretic so that when the blood alcohol level (BAL) is high, the secretion of the antidiuretic hormone is suppressed. Since this diuretic effect does not occur when the BAL is constant or falling, the alcoholic may then retain water.
9. Skin-- Skin conditions such as palmer erythema, spider angiomata, rosacea, rhinophyma, porphyria cutanea tarda, and bronzed cirrhosis may be seen.
10. Blood-- Alcohol decreases the production of all types of blood cells. Macrocytosis (large red-blood-cell anemia) resulting from a folic acid deficiency is often a sign of alcoholism. Decreased production and efficiency of white cells make the alcoholic susceptible to more infections, and decreased production of clotting factors and platelets lead to increased bruising and gastrointestinal bleeding. The higher incidence of cancer seen in alcoholics may be related to the decrease in thymus-derived lymphocytes.
11. Cancer-- Alcohol consumption is associated with cancers of the mouth, larynx, tongue, esophagus, liver, lung, head, and neck. The risk of cancer is increased about one third in those who drink heavily and may be a result of numerous factors, some of which are nutritional deficiencies, a damaged liver that cannot detoxify carcinogens, cellular injury resulting in metabolic changes, or alcohol itself causes cancer.
12. Nervous system and Brain-- Alcohol acts as a depressant on various brain structures and damages the CNS and peripheral nervous systems by modifying neurotransmitter levels and cell membrane fluidity and function. A peripheral neuropathy is seen in 5-15% of alcoholics.
Organic brain syndrome (OBS) can be temporary or permanent and are associated with both the direct effect of alcohol and with vitamin deficiencies.
Korsakoff's psychosis is an organic mental syndrome in which the patient is disoriented, confused, unable to recall events, and extremely susceptible to suggestion. Usually the patient also has polyneuropathy and Wernick's syndrome: The patient is ataxic, has nystagmus, and ocular muscle palsies. The brainstem is under attack by neuretic and hemorrhagic lesions. The underlying problem is a vitamin deficiency of thiamine. The patient should be immediately admitted to a hospital and given parenteral doses of 50 to 100 mg of thiamine daily, supplemented by oral B-complex vitamins and ascorbic acid.
Dementia associated with alcoholism is another OBS. Here, the patient shows signs of severe loss of intellectual function, and memory impairment. This pattern is seen in long-term alcoholics. In its most severe form, the patient may have emotional instability, disintegration of personality and social function, and overt signs of dementia; but the diagnosis is made on the results of neuropsychological tests. The mild form can be treated in an ambulatory, alcoholic treatment program, but strong efforts must be made to get the patient to stop drinking. If he cannot do so, he should be placed in a residential treatment center.
Alcoholic idiosyncratic intoxication is a rare phenomenon that produces a severe change in mental state and behavior after an individual drinks only a small amount of alcohol. The individual may become confused, have transitory delusions, visual hallucinations, and transient loss of consciousness. He may become enraged, aggressive, destructive, or may be depressed and suicidal. This state lasts for only a few hours to a few days, and is best treated with sedation in the hospital. These people can be dangerous to themselves and others. After a period of sleep, this clears and the individual will not recall the episode.
13. Sleep Patterns-- Alcohol interferes with normal sleep by decreasing the deep sleep stages and causing frequent awakenings. These problems may persist for three to six months during abstinence, and gradually a normal sleeping pattern returns.
14. Nutrition-- The alcoholic may obtain more than one-half his daily calories from alcohol (which has no nutritional value) and neglect eating food. In addition, alcohol suppresses appetite through its effect on the CNS. Disease of the GI tract, liver, and pancreas may further decrease intake and absorption and contribute to malnutrition. Alcoholics are lacking in vitamins, particularly the B vitamins. The metabolism of iron is altered by alcohol and the alcoholic needs to be evaluated for idopathic hemochromatosis only after a complete review of his case. A reversal of overload is possible with B vitamin therapy and abstinence.
15. Reproductive System-- Chronic alcoholism inhibits normal testicular, pituitary, and hypothalmic function. Impotence, decreased libido, and decreased testosterone levels may result. Men with cirrhosis of the liver may develop hyperestrogenization (feminization). After three months of abstinence, sperm count, motility, and ejaculate volume tend to improve.
16. Fetal Alcohol Syndrome-- Alcohol crosses the placenta and can result in fetal alcohol syndrome (FAS), which is characterized by physical abnormalities and developmental retardation, and is now recognized as the leading known cause of mental retardation. The severity of the effects depends upon the amount of alcohol ingested during pregnancy. With total abstinence, there is no risk; with two or three drinks daily, there is a moderate risk and severity; with six or more drinks daily, there is high risk of severe abnormalities including mental retardation, poor coordination, irritability, hyperactivity, microcephaly, and low birth weight.
17. Hangover-- There is temporary, acute physical and psychological distress following excessive consumption of alcoholic beverages. The experience known as hangover has been related to the amount of congeners (non-alcoholic components) in beverage alcohol; the type of food eaten and liquor consumed; various emotional influences and expectations; the impact of physical factors, including loud and dark drinking environments; and physical factors, especially fatigue. Nausea, gastritis, headache, and anxiety experienced are painful reminders of disrupted body functions that could not be felt while intoxicated. A hangover is the body's reaction to excessive drinking and represents a pronounced withdrawal syndrome from relatively large amounts of alcohol. Despite some innovative hangover cures, the only effective cures have been the use of analgesics for headaches and the healing powers of time.
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