reinforces the likelihood of repeated consumption through motivation and routine behaviors. The repeated activation of the basal ganglia changes the way an individual responds to stimuli, which then triggers powerful urges to consume the substance over time. 2. Negative affect/withdrawal stage occurs when an individual stops drinking and withdrawal symptoms occur. These symptoms can be physical (sleep disturbances, pain, and ill feelings) or emotional (dysphoria, irritability, anxiety, and emotional pain). Negative feelings associated with alcohol withdrawal come from two sources. Diminished activation in the reward system makes it difficult to experience the euphoria associated with Alcohol intoxication Alcohol intoxication usually develops over minutes to hours and lasts about several hours. The first episode of alcohol intoxication most commonly occurs in the mid-teens, but alcohol use disorder is not typically identified in late teens or early 20s. The essential feature of alcohol intoxication is the presence of behavioral or psychological changes, including inappropriate sexual or aggressive behavior, mood lability, impaired judgment, and levels of incoordination that may interfere with the performance of usual activities. The degree of intoxication increases with the blood alcohol concentration, especially when combined with other sedation-producing substances. 4 If an individual lacks significant impairment at 150 mg/ dL, pharmacodynamic tolerance may be present. 23 However, an individual’s history of regular exposure to alcohol dictates the behavior that follows its consumption since the human body and the central nervous system can develop tremendous tolerance to ethanol. Mental and physical dysfunctions from Alcohol withdrawal Alcohol withdrawal can occur with anyone with alcohol use disorder and symptoms can range from mild to severe and occasionally life threatening. Minor symptoms include anxiety, tremor, diaphoresis, palpitations, nausea and vomiting. The symptoms can be progressive and severe, eventually leading to seizures and autonomic hyperactivity. The classic sign of alcohol withdrawal is tremulousness. 23 Alcohol withdrawal seizures typically occur within 6-48 hours after cessation of drinking in a habituated alcohol drinker and occur in 10-30 percent of patients in alcohol withdrawal. Alcohol withdrawal can produce generalized tonic clonic seizures, but status epilepticus is rare. 23 The estimated progression of alcohol withdrawal symptoms is presented in Table 2. 23
everyday living. Increased activation of brain stress contributes to anxiety, irritability, and unease. The individual consumes alcohol to escape the lows of chronic alcohol use. 3. Preoccupation/anticipation stage occurs when an individual seeks alcohol after a period of abstinence. This stage can be triggered by various factors such as stress, social situations, or environmental associated with previous substance use. These triggers can create a psychological and physiological response in the brain, leading to a strong urge to use alcohol. The prefrontal cortex, responsible for executive function, is compromised in alcohol use disorder. 133 ethanol, in an alcohol-tolerant individual, do not consistently correlate with ethanol levels traditionally used to define intoxication, or even lethality, in a nontolerant subject. 22 Table 1: Blood Alcohol Concentrations (BAC) with Impairment 20-30 mg/dL Slowed motor impairment with decreased thinking ability 30-80 mg/dL Increased motor and cognitive problems 80-200 mg/dL Incoordination and judgment errors with deterioration in cognition 200-300 mg/dL Nystagmus, slurred speech, and blackouts >300 mg/dL Impaired vital signs and possible death
Table 2: Alcohol Withdrawal Progression Progression Symptoms Time to
Presentation
Mild
Tremulousness 6-8 hours
Moderate
Perceptual disturbances
8-12 hours
Severe
Seizures
12-24 hours
Life Threatening
Delirium tremens
Within 72 hours
Evaluation of the severity of withdrawal includes physical examination and the use of the CIWA score. The Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) scale has 10 items, each evaluated independently and then aggregated to yield a score correlating with severity of alcohol withdrawal. 23
Book Code: MDCO1025
Page 49
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