Alcohol Use Disorder

AUD: Definition & Epidemiology - The Indian Pint‑demic

• Definition (DSM-5): Problematic alcohol use; ≥2 of 11 criteria in 12 months, causing distress/impairment.
• Indian Prevalence (NDDUS 2019, 10-75 yrs):
  • Current users: ~14.6% (~160 million).
  • Dependence: ~2.7% (~29 million); M:F ratio ~17:1.
  • Higher in e.g., Arunachal Pradesh, Tripura, Punjab.
• Key Risk Factors: Genetic predisposition, early initiation, peer pressure, comorbid mental health conditions.

⭐ In India, ~40% of road traffic accidents are attributable to alcohol use (NDDUS 2019).

AUD: Neurobiology & Pathophysiology - Brain Under the Influence

• Acute Effects: Enhances GABAergic (inhibitory) transmission (sedation, anxiolysis); inhibits NMDA glutamatergic (excitatory) transmission. Releases dopamine in mesolimbic pathway (reward).
• Chronic Use & Neuroadaptation:
  • ↓ GABA-A receptor function & density.
  • ↑ NMDA receptor density & sensitivity (upregulation).
  • Dysregulation of dopamine, serotonin, and opioid peptide systems.
• Withdrawal Syndrome: Results from abrupt cessation. Characterized by CNS hyperexcitability (↓GABA, ↑glutamate activity) → tremors, anxiety, seizures, delirium tremens.
• Kindling: Repeated withdrawal episodes sensitize the brain, lowering seizure threshold.

⭐ Chronic alcohol exposure leads to a hyperexcitable state upon cessation due to GABA receptor downregulation and NMDA receptor upregulation, underlying withdrawal symptoms like seizures and DTs.

AUD: Clinical Features & Diagnosis - Signs of the Spirits

• Intoxication: Slurred speech, incoordination, nystagmus, impaired memory.
• Withdrawal (6-24h onset):
  • Autonomic hyperactivity (↑HR >100, sweating)
  • Tremor, insomnia, N/V, anxiety
  • Hallucinations (visual/tactile)
  • Seizures ("rum fits", 12-48h)
  • Delirium Tremens (DTs, 48-96h): Disorientation, agitation, fever, ↑autonomic signs. Emergency!
• Diagnosis (DSM-5): ≥2 criteria/12mo (impaired control, social issues, risky use, tolerance/withdrawal).
  • Severity: Mild (2-3), Moderate (4-5), Severe (≥6).
• Markers: ↑GGT, ↑MCV, AST:ALT >2. CDT for chronic use.

⭐ Wernicke's Encephalopathy triad: Confusion, Ataxia, Ophthalmoplegia (📌 CAO). Often incomplete.

AUD: Complications - The Hangover's Harm

• Neuro: Wernicke-Korsakoff (Thiamine def.), cerebellar degen., neuropathy, seizures, hepatic encephalopathy.
• GI: Gastritis, PUD, Mallory-Weiss, varices, pancreatitis, ALD (steatosis, hepatitis, cirrhosis → HCC).
• CVS: Alcoholic cardiomyopathy, HTN, arrhythmias (holiday heart).
• Psych: Depression, anxiety, ↑suicide risk, psychosis.
• Heme: Macrocytosis, thrombocytopenia.
• Metabolic: Hypoglycemia, alcoholic ketoacidosis.
• Other: Fetal Alcohol Syndrome (FAS).

⭐ Wernicke's encephalopathy triad: Confusion, Ataxia, Ophthalmoplegia (📌 CAO). Reversible with IV thiamine before glucose administration to prevent precipitation/worsening of Wernicke's.

AUD: Management - Path to Sobriety

• Withdrawal Management:
  • Benzodiazepines (e.g., Chlordiazepoxide, Lorazepam): Symptom-triggered or fixed-schedule, guided by CIWA-Ar (target < 8-10).
  • Thiamine 100mg IV/IM daily for 3-5 days (prevents Wernicke-Korsakoff).
  • Supportive care: IV fluids, electrolytes.
• Maintenance (Relapse Prevention):
  • Naltrexone (50mg OD / long-acting IM): Reduces craving & heavy drinking.
  • Acamprosate: Supports abstinence by reducing protracted withdrawal.
  • Disulfiram: Aversive therapy (aldehyde dehydrogenase inhibitor). ⚠️ Monitor LFTs.
  • Psychosocial therapies (AA, CBT, MI) are essential adjuncts.

⭐ Naltrexone can be initiated while still drinking to reduce consumption; Acamprosate/Disulfiram require abstinence.

High‑Yield Points - ⚡ Biggest Takeaways

• CAGE questionnaire (Cut down, Annoyed, Guilty, Eye-opener) is a key screening tool.
• Delirium tremens (DT): severe, life-threatening withdrawal, peaks 48-96 hours post-cessation.
• Wernicke-Korsakoff syndrome: from thiamine (B1) deficiency; Wernicke's (reversible triad), Korsakoff's (irreversible amnesia).
• Key drugs: Disulfiram (aversive), Naltrexone (↓ cravings), Acamprosate (maintains abstinence).
• Elevated GGT & MCV are common biochemical markers of chronic alcohol use.
• Acute alcohol withdrawal: manage with benzodiazepines (e.g., chlordiazepoxide, lorazepam).
• Fetal Alcohol Syndrome (FAS): distinct facial dysmorphism, growth deficits, CNS issues.