Alcohol: The Mother of All Evils

Alcohol: The Mother of All Evils

ام الخبائث

“Surely intoxicants, gambling, dedication of stones and divination by arrows are an abomination of Satan’s handiwork, keep away (from them) so that you may prosper.”

(Holy Quran 5:90)

Introduction

Alcohol has been stated by Prophet Muhammad (PBUH) as to be the mother of all evils and science/medicine and reality have proved this statement today. As we shall see in this blog, almost every organ system is affected besides many socioeconomic problems.

Alcohol is chiefly important in medicine because of the consequences of its misuse/abuse. In the western countries approximately one-quarter of male patients in general hospital medical wards have a current or previous alcohol problem. It is the cause of more preventable morbidity and mortality than all other drugs combined, with the exception of tobacco.

On a molar basis alcohol is consumed more than any other drug. In some societies in the west it is still preferred over water.

Alcohol misuse is a social problem with pharmacological aspects. Men are more likely to have alcohol-related problems than women, although the gap is now closing.

We shall study the Pharmacology of this drug in the blog along with relative comments.

PHARMACOKINETICS

Absorption

Ethanol when taken orally is rapidly absorbed from the intestine especially the stomach and the small intestine. This is due to it being uncharged and highly lipid soluble.

Absorption is delayed by increasing concentrations due to inhibited gastric peristalsis.

Absorption is also delayed by the presence of food especially milk and carbohydrates.

Alcohol undergoes gastric first-pass metabolism by the presence of the enzyme alcohol dehydrogenase in the wall of the stomach (but not in the intestinal wall). Therefore the more rapid the absorption, the less the first pass metabolism. So drinking alcohol on an empty stomach produces greater pharmacological effects.

Distribution

Ethanol is rapidly distributed throughout the body water. It is not selectively stored in any tissue.

Women have a higher peak blood concentration than men, because women have lower total body content and because the stomach wall in women has less alcohol dehydrogenase, so ethanol undergoes less first-pass metabolism.

So the maximum blood concentration after absorption depends on numerous factors:

Total dose
Sex
Strength of the solution
Time over which it is taken
Presence or absence of food
The kind of food eaten
Individual variations.

Metabolism

Over 90% of ethanol absorbed is oxidized in the liver.

It is metabolized to acetaldehyde by two pathways:

1. Alcohol dehydrogenase is an enzyme found mainly in the liver but also located in the brain, stomach and other organs. It converts ethanol into acetaldehyde using NAD⁺as a cofactor and converting it into NADH. This excess NADH production accounts for the various metabolic disorders to be described below.

Acetaldehyde Metabolism

Acetaldehyde is then converted into acetic acid by the enzyme aldehyde dehydrogenase, aldehyde oxidase and other enzymes but especially the former.

Acetic acid can be further metabolized to CO2 and H2O through the citric acid cycle.

2. Microsomal Ethanol Oxidizing System (MEOS)

This enzyme system also called the mixed function oxidase system uses NADP⁺ as a cofactor and converts ethanol to acetaldehyde.

This system comes into function mainly when the alcohol dehydrogenase system is saturated due to depletion of the cofactor NAD⁺. As the concentration of ethanol increases above 100 mg/dl there is increased contribution from the MEOS.

3. Catalase is also another enzyme that metabolizes ethanol.

Excretion

The remaining alcohol is excreted in the breath, urine and sweat. The alcohol breath test is now the means of estimating the blood alcohol concentration and is used at the roadside by motor policemen in many western countries.

Alcohol Undergoes Zero Order Kinetics

Alcohol undergoes zero order kinetics of elimination from the body. It is only one of the three drugs that does so.

This means a constant AMOUNT of drug gets eliminated per unit time, not a constant FRACTION, like most drugs. This makes its rate of elimination very slow.

If it had undergone first order kinetics, a person drinking alcohol at night maybe all fresh in the morning as all the alcohol may get eliminated from the body very rapidly.

But no, God Almighty, the All-Knowing made alcohol one of the 3 drugs undergo zero order kinetics so that an alcoholic waking up in the morning will still be drunk etc in the morning and will have more chance of developing all the acute and chronic adverse effects of alcohol. Subhan Allah! (Glory be to God).

How Long Alcohol Stays in the Body?

1. Everyone metabolizes alcohol at a different rate.
2. Age, body weight, and the amount and type of alcohol you’ve consumed are all factors that affect how long it stays in your system.
3. Hair tests can detect alcohol for up to 90 days.

Maybe this is why the Holy Prophet (PBUH) stated:

Mechanism of Action

The exact mechanism of action is unclear but the main theories are:

Enhancement of GABA mediated inhibition. Ethanol enhances the action of GABA at GABA receptors, just like benzodiazepines.
Ethanol has an inhibitory effect on glutamate activation of NMDA receptors in the CNS. The NMDA receptor is thought to be involved in cognitive functions like learning and memory.
It inhibits the opening of voltage gated Ca channels in neurons.
It inhibits transmitter release in response to nerve terminal depolarization. It may depress action potentials in the nervous system.
More recently it is thought that ethanol interacts directly with proteins that mediate transmembrane signaling such as receptor gated ion channels.
Enhancement of excitatory effects of serotonin 5-HT3

Actions of Alcohol

These can be grouped into acute or chronic effects of ethanol intake, depending upon the relative duration of ethanol intake.

Acute Effects

CNS

These effects are well-known and the condition is usually called intoxication or drunkenness in which the person shows slurred speech, motor in-coordination, increased self-confidence and euphoria, sedation, relief of anxiety, ataxia, impaired judgement and disinhibited behavior are also produced.

The Prophet Muhammad (PBUH) has said, “ Wine is the source of all obscenity; it is the greatest of sins, and whoever drinks leaves his prayer and assaults his mother and his aunt.”

Psychic effects are the most important socially, and it is to obtain these that the drug is habitually used in so many societies to make social interaction not merely easy but even pleasant.

It is related that a licentious woman seduced a righteous man but he refused. So she offered him wine which he drank and thus completed her wish!

How many incidents like these are seen in the western countries?

Environment personality mood and dose of alcohol all affect the final condition of the person.

Both mental and physical efficiency is reduced by alcohol in any amounts except in a few people (discussed later).

Results show that alcohol reduces visual acuity impairs taste, smell and hearing, and prolongs reaction time. It also causes nystagmus and vertigo.

Due to the increased confidence in their ability these people often underestimate their errors. Attentiveness and ability to assimilate and quick judgment ability is decreased other social problems will be discussed later.

Acute ‘Beneficial’ Effects

Relief of anxiety
Increased self-confidence
Euphoria
Sedation

Disadvantages much more than the benefits as stated in the Divine Book:

TOXIC DOSES RESULT IN:

Acute Alcohol Poisoning

Like other sedative hypnotics alcohol is a CNS depressant. This results in anesthetic action with profound respiratory depression.

This can result in coma and death.

These CNS effects are most marked when the blood alcohol levels are rising. For chronic alcoholics much higher concentrations are needed to produce the same effects. A chronic alcoholic may appear only slightly intoxicated with a blood alcohol cone of 300-400 mg/dl whereas this level is associated with marked intoxication or even coma in a non-tolerant person.

Acute CVS Effects

The main CVS effect of alcohol is to produce cutaneous vasodilation. This is because it depresses the vasomotor center causing the feeling of warmth that follows taking the drug. This can cause increased heat loss and hypothermia may result especially felt in cold weather if alcohol is drunk excessively.

Depression of myocardial contraction

An acute dose may also raise the blood pressure probably through central sympathetic stimulation.

Gastrointestinal (GIT) Effects:

Ethanol increases salivary and gastric secretion. The gastric mucus may shows erosions and petechial hemorrhages after an acute excessive intake.
Decreased GIT motility and irritation are also produced.
Central and local gastric effects produce nausea and vomiting.
Beginners and Asians develop flushing, headache and nausea because of deficiency of aldehyde dehydrogenase and therefore acetaldehyde accumulation.

EFFECTS OF CHRONIC ALCOHOL CONSUMPTION

Chronic effects caused by alcohol are due to:

Oxidative Stress
Generation of free radicals
Depletion of glutathione
Damage to Mitochondria
Increased cytokine induced injury

Alcohol adversely affects every system of the body on chronic intake:

Effects of Alcohol on the Liver

Liver disease is the most common medical complication of alcohol abuse.

Many (as much as 15-30 %) of chronic drinkers eventually develop severe liver disease.

As mentioned above there is reduced hepatic metabolism of lipids and increased triglyceride formation from fatty acids due to decreased NAD⁺/ NAD ratio resulting from alcohol metabolism. This conditions proceeds to fatty liver that is reversible. This may then progress to cirrhosis and liver failure. In many countries ethanol is the most common cause of liver failure and of the need for liver transplantation.

Clinically significant alcoholic liver disease may be insidious at the onset and progress without evidence of overt nutritional abnormalities.

The progress to development of liver disease depends upon the amount of daily consumption and to the duration of alcohol abuse. One other main factor is malnutrition because alcohol only provides calories but no vitamins, minerals or amino acids. Concurrent infection with viral hepatitis B or C may also increase the risk of liver failure.

Esophageal varies is also a complication of liver cirrhosis.

Effect on GIT System

Because of increased gastric and pancreatic secretions by ethanol there is increased incidence of gastritis and pancreatitis. Also ethanol has direct toxic effects on the mucosal membranes of the stomach that may cause gastritis.

Increased incidence of GIT bleeding besides the variceal bleeding due to liver cirrhosis.

Esophagitis and chronic pancreatitis.

Malabsorption of vitamins especially water-soluble vitamins contributes to the clinical abnormalities.

Increased susceptibility to blood and protein loss due to chronic drinking.

Reversible injury to small intestine resulting in diarrhoea and weight loss.

Endocrine Effects

Ethanol inhibits the secretion of ADH by the posterior pituitary. This results in diuresis but tolerance develops quickly.

The secretion of oxytocin is also inhibited by ethanol. So labor is delayed.

Alcohol if taken in excess with a meal can enhance the normal insulin response to carbohydrate intake and lead to hypoglycemia. Some alcoholics develop hypoglycemia due to impaired hepatic gluconeogenesis.

Ethanol increases the output of adrenal steroid hormones by stimulating the anterior pituitary gland to secrete ACTH Metabolism of hydrocortisone is decreased by ethanol in the liver.

Chronic male alcoholics often show signs of feminization like gynecomastia and testicular atrophy.

Females have problems of infertility.

Metabolic Effects

Intake of Alcohol reduces glucose uptake by the tissues leading to an initial increase in blood glucose.

But alcohol also inhibits gluconeogenesis and a fasting person or a person whose hepatic glycogen is low may experience a hypoglycemic attack severe enough to cause irreversible brain damage.

This is due to the decreased NADH/NAD ratio caused by alcohol metabolism.

This disturbed ratio also causes increased triglyceride formation from fatty acids, and decreased metabolism of lipids.

Hyperuricemia occurs with precipitation of gout due to increased catabolism of adenine nucleotides resulting in increased production of uric acid and its precursors.

Acute Hepatitis may occur in a rare case of very heavy drinking.

Effect on Smooth Muscle

It directly relaxes smooth muscle caused by its metabolite acetaldehyde.

Ethanol also relaxes uterine smooth muscle and for this it was used previously for premature labour.

Effect on Sexual Function

Ethanol is known to increase sexual desire but it decreases or impairs the sexual performance. Males have problems of being cold and rigid. Performance in athletes is also impaired.

Chronic Effects on the C.N.S.

Along with liver damage, brain damage is the most serious long-term consequence of excessive ethanol consumption.

Most common is generalized symmetrical peripheral neuropathy that starts with distal parasthesias of the hands and feet.

The majority of chronic alcoholics show a degree of dementia associated with ventricular enlargement.

Patients may also have gait disturbances and ataxia that are due to cerebellar degeneration.

Wernick-Korsakoff’s syndrome is an important feature of chronic alcoholics associated with co-existing thiamine deficiency. It is characterized by paralysis of the external eye muscles, ataxia, attacks of loss of memory and a confused state that can progress to coma and death. Also known as Alcohol amnesic disorder.

Alcohol may impair visual acuity with painless bilateral blurring. Optic nerve degeneration may follow.

Psychosis and seizures may also occur.

Cerebral hemorrhage may also occur.

Chronic C.V.S. Effects

Chronic Heavy alcohol drinking is associated with a dilated cardiomyopathy with ventricular hypertrophy and fibrosis leading to congestive heart failure.

Heart failure is one of the most common causes of death due to chronic alcohol intake besides liver failure and pancreatitis.

These are due to changes in heart cells.

Heavy drinking is associated with both atrial and ventricular arrhythmias.

Heavy use of alcohol is also an important cause of hypertension.

Incidence of ischemic heart disease has been found to be lower in both men & women who drink moderate amounts of ethanol. (Discussed ahead)

Effect on Blood

Ethanol impairs hematopoiesis and also indirectly inhibits proliferation of all cellular elements in the bone marrow i.e. bone marrow depression.

Anemia is the most common blood disorder seen in chronic alcoholics. This is due to alcohol related folic acid deficiency; iron deficiency anemia may also contribute due to GIT bleeding.

Deficiency of Vitamin K dependent clotting factors (liver disease).

Ethanol inhibits platelet aggregation, by inhibition of arachidonic acid formation from phospholipids.

Ethanol in low to moderate doses may increase HDL and decrease LDL.

These last two effects i.e. effect of inhibition of platelet aggregation and increase in HDL exert a protective effect against atheroma formation and therefore protective against ischemic heart disease (discussed further in uses).

Malnutrition

Alcoholics take most of their calories from drinking ethanol that provides 7 Kcal per gm mole. But this does not provide vitamins, amino acids, minerals and other necessary nutrients.

Therefore they develop deficiency symptoms of different vitamins especially vitamin B, (thiamine) and other group B vitamin.

This malnutrition complicates the other long-term effects of alcohol intake: –

E.g. Essential factors such as glutathione are decreased in a malnourished alcoholic. Glutathione is a valuable scavenger of toxic free radicals and therefore its deficiency will cause injury to the liver by the toxic free radicals.

Malnutrition is also caused by malabsorption of vitamins and other nutrients.

Thiamine deficiency combined with alcoholism may result in the Wernicke’s Korsakoff’s syndrome.

Electrolyte Imbalance

These include ascites, edema and effusions. These factors may be related to decreased protein synthesis and portal hypertension.

Hypokalemia may develop due to vomiting and diarrhoea and worsened by diuretics.

This as well as severe secondary aldosteronism may contribute to muscle weakness.

Immune System & Cancer

Due to malnutrition and direct impairment of immune function alcoholics have increased rate of infections and are especially prone to respiratory infections like pneumonia and tuberculosis.

This also accounts for the increased risk of cancer in these alcoholics.

Immunological changes include alterations in chemotaxis of granulocytes. Increased number and activity of natural killer cells and increased levels of tissue necrosis factor (TNF) are also observed.

Cancers include cancer of the mouth, pharynx, larynx, esophagus and liver.

Breast cancer in women.

Skin & Muscle

Psoriasis and the dermatological features of liver failure including spider nevi and palmar erythema.

Acne rosacea also occurs.

Myopathy also results.

Lactation & Alcohol

Even small amounts of alcohol taken by the lactating mother delay motor development in the child.

Fetal Alcohol Syndrome (FAS)

This is due to chronic maternal alcohol abuse during pregnancy. This syndrome is characterized by some features in the newborn that collectively give us the diagnosis of this syndrome. These include:

Retarded body growth

Abnormal facial development, wide set eyes, short palpebral fissures.

Reduced cranial circumference

Mental retardation and behavioural abnormalities

Other anatomical abnormalities e.g. congenital cardiac abnormalities, malformation of the eyes and ears etc.

Poor coordination

Minor joint abnormalities.

Ethanol is responsible for 8% of cases of mild mental retardation. Drinking in the first trimester has the most effects on fetal development; drinking in the last semester affects growth.

Increased incidence of spontaneous abortion

There is no ‘safe’ dose which can prevent any small fetal malformation, therefore total abstention is most safe and this includes women who wish to become pregnant as drinking can also effect the fetus in the first few weeks of life.

Why permanently punish innocent new born children by drinking?

Psychosocial Problems with Chronic Alcohol Drinking

“Satan’s plan is but to excite enmity and hatred between you with intoxicants and gambling and hinder you from the remembrance of Allah and from prayer, will you not then abstain?”

Al-Quran (5:91)

Alcoholism is one of the leading causes of violence in the U.S.A. and other western countries. Most crimes are carried out under the influence of alcohol including rape, murder, motor vehicle accidents etc.

Alcohol & Driving

“Don’t drink and drive” is a common saying in the west.

Many countries have made laws designed to prevent motor accidents caused by alcohol but the problem has not been solved. Thousands still die and are injured because of accidents due to drunk driving. In fact about 50% of traffic accidents are due to drunk driving.

This is why the breath analyzer test was introduced mainly in these western countries to analyze the blood alcohol concentration at the roadside. Drunk driving causes the following effects even in moderate doses:

Drivers attempt to pass through gaps less than the width of their vehicle
Increased distractability
Over confidence or excessive caution
Inability to deal with crisis in a road scene e.g. animals coming on to the road; driver will not know what to do.
Tendency to drive in the middle of the road.
Inaccurate turns at the corner.
Prolonged reaction time
Look of colour discrimination e.g. red, yellow or green light
Bad judgment in overtaking or turning etc.
Tendency to have accidents on one’s own e.g. bumping into a light pole
Delayed recovery from dazzle etc.

Driving can be further impaired if other drugs are taken along with alcohol (see drug interactions).

These are all due to the affects on the C.N.S. including decreased visual acuity, nystagmus, vertigo, ataxia, in-coordination of motor movements, underestimation of errors etc.

So, there is no safe limit for driving. “If you drive, don’t drink, and if you are drunk, don’t drive”.

Other Social Problems

These include family and work problems.

There is increased incidence of absenteeism from work due to alcohol drinking; increased unemployment resulting in financial problems; difficulty with the boss and colleagues.

Marital problems including daily arguments and fights; child abuse is much more common among alcoholics, divorce rate is high.

Problems with the law enforcing authorities like police due to violence, crime or drunk driving.

Psychological Problems

Depression is very common and is also due to the various social problems these people have.

Alcohol also has a direct depressant effect.

Suicide and attempted suicide is much more common among alcoholics than the rest of the society.

This is why the Holy Prophet (PBUH) has called it the ‘Mother of all Evil deeds’.

Morbid Jealousy

This is a psychological syndrome characterized by delusions that one’s partner is having a sexual affair with someone else.

This can be due to the patient’s own problem of impotence and rejection by his partner.

This leads to paranoid delusions and he accuses his partner of having a relationship with another person.

He even tries to obtain evidence such as spying, checking her possessions repeatedly or even hiring a private detective.

This may lead to domestic violence and even murder of the spouse.

This morbid jealousy is caused by alcohol drinking. It may also occur in schizophrenics, depressive illness and paranoid personality disorder.

Other psychological problems associated with drinking include increased anxiety, mania or hypomania, eating and sleep disorders etc.

Tolerance Dependence & Abuse

Like most drugs of abuse ethanol also produces tolerance, dependence and addiction.

It would cost the chronic drinker 2 ½ times as much to get visibly drunk, as it would cost a beginner. This is due to enzyme induction and adaptation of the central nervous system.

Dependence varies from person to person. This is physical and psychological dependence.

A withdrawal syndrome develops upon abrupt stoppage of ethanol intake (discussed later).

It is the most commonly abused drug in the world after nicotine.

Psychological dependence upon alcohol is characterized by a compulsive desire to experience the rewarding effects of alcohol and a need to avoid the negative consequences of withdrawal.

People who have abstained from drinking alcohol experience an intense craving for alcohol when meeting friends or people with whom one used to drink or at places where one used to drink or by other environmental cues.

WITHDRAWAL SYMPTOMS:

Due to the physical dependence of alcohol described above, alcohol should never be stopped abruptly because this can be serious.

The earliest manifestation is a subjective sensation of tension on waking up in the morning, (this is why alcoholics take a drink after waking up).

This may be accompanied by a tremor that makes it difficult to shave or hold a cup of tea.

More serious symptoms include epilepsy and delirium tremens. The latter is a confusional state characterized by impaired consciousness, visual hallucinations, memory disturbance and seizures. This is an emergency condition (management described later).

Alcoholic hallucinosis may also occur. These are mainly auditory in the form of derogatory or persecutory voices that discuss the person or directly comment to him (similar to schizophrenic hallucinations).

Other features include irritability and apprehension;

Anorexia, nausea and vomiting, autonomic hyperactivity, hypertension, diaphoresis and hyperthermia; which may progress to delirium tremens.

TREATMENT OF ALCOHOL ABUSE:

Alcohol is a Drug. Say no to drugs.

Become a Teetotaler:

A teetotaler is a person who has never taken alochol.

Prevention is the best cure so. The best is to keep away and totally abstain from drinking alcohol.

But how can one influence someone not to drink?

Factors Influencing Drinking

Social peer pressure
Lack of parenteral guidance & monitoring
Genetics
Psychosocial problems: depression, anxiety, stress (in job, family studies, etc)
Tolerance & Dependence
Lack of faith

Lack of Faith

This is one of the most important factors as can be illustrated in the example below:

The U.S. Government banned alcoholic drinks officially in 1920 in an attempt to solve the problems of drinking.

Pamphlets, books and films were shown; 65 million dollars were spent in 10 years before prohibition and about 4 ½ million pounds in 14 years of prohibition. These were huge, huge amounts in those days.

In enforcing this law, 200 people were killed, half a million imprisoned fines over half a million pounds imposed and 400 million pounds worth property confiscated.

This was all to instruct the civilized American society of the harms, (spiritual, medical, social and economical) of drinking.

What was the result?

As soon as the ban was lifted a thousand bars were opened. The price of alcohol increased. The number of drinkers after prohibition increased 10 times as before.

Why? The American Government had failed? Why? While our Prophet (PBUH) and Islam succeeded 1400 hundred years before.

It is stated in many authentic Ahadith that when the prohibition of drinking came, wine flowed through the streets of Madina that day like rivers of blood, never to be drunk again in that city.

Why? The root cause is faith in Allah and one’s religion.

Christianity and its teachings enjoins drinking alcohol:-

“Alcohol is for people who are dying, for those who are in misery. Let them drink and forget their poverty and unhappiness”.

Bible: Proverbs 31:6-7

“Drink no longer water, but use a little wine for thy stomach’s sake and thine often infirmities”

Bible 1 Timothy 5:23

So Alcohol is recommended in preference to water! This is the Christian faith and preaching. This is why Americans could not and still cannot stop drinking. Their lord and faith tells them to keep on drinking.

While Islam and the Quran says as mentioned above.

“………. Keep away from them so that you may prosper”.

Al-Quran (5:90)

Islam can rightly boast that it has the largest amount of teetotalers-those people who abstain totally from drinking alcohol. And the people of Islam have far less or negligible problems due to Alcohol drinking which have been mentioned above.

This is why our Prophet (SAW) has said:

“Whenever a person drinks wine he is not a believer while drinking.

Management Strategies

Straightforward advice about the harmful effects of alcohol as needed.

Supportive psychotherapy, interpretive psychotherapy can help prevent relapses.

This type of help is offered by Organizations like Alcoholics Anonymous (AA) in America and other western countries. But as mentioned above total abstention as ordered by Islam is the best.

Pharmacological Treatment

1. Drugs for Prevention (Treatment of Alcoholism)

Disulfiram

This drug inhibits aldehyde dehydrogenase resulting in the accumulation of toxic levels of acetaldehyde with nausea, vomiting, flushing, headache, sweating, hypotension and confusion lasting upto 3 hours. This occurs only after drinking alcohol (not by itself).

It can be toxic in the presence of small amounts of alcohol.

After the symptoms end, the patient usually is exhausted and sleeps for several hours.

Since this reaction is very unpleasant it will hinder the patient from drinking alcohol.

Disulfiram should only be used along with behaviour therapies.

Management should be started 24 hours after total abstinence of alcohol.

Dose is 250 mg daily at bedtime in oral dose.

It may cause mild changes in liver function.

Other drugs also have disulfiram-like effects. (see drug interactions)

Naltrexone

This is an orally available opioid receptor antagonist that blocks the effects of exogenous and endogenous opiods.

So it decreases the craving for alcohol and decreases the pleasure experienced by drinking.

This is also accompanied by psychotherapy.

It is also hepatotoxic, so it should not be taken with disulfuram.

Dose is 50 mg orally daily.

Side effects include nausea, dizziness and headache and liver dysfunction.

May cause withdrawal symptoms in opioid addicts.

Acamprosate

A weak NMDA-receptor antagonist and a GABA A receptor activator

Other drugs

Several other neurotransmitters systems are being studied.

Serotogenic and dopaminergic systems participate in the regulation of alcohol consumption.

Clinical trials on SSRI’s like fluoxetine and serotonin receptor agonists like Buspiron are going on.

Treatment of Withdrawal Symptoms

The major objective of drug therapy in the withdrawal period is prevention of seizures, delirium and arrhythmias.

Potassium, magnesium and phosphate balance should be restored as rapidly as possible. Thiamine is also indicated in all cases.

For delirium tremens benzodiazepines are given along with phenytoin to prevent or reverse seizures.

Clonidine or Propanolol may be given in place of benzodiazepines. Electrolyte balance must be restored along with nutritional support. Benzodiazepines are given parentally.

For detoxification benzodiazepines are substituted for alcohol, especially the long acting benzodiazepines like diazepam, chlorazepate, and chlordiazepoxide since less dosing is required.

However short-acting benzodiazepines like oxazepam are used in-patients with liver disease since the former accumulate in the liver.

After the treatment of withdrawal has been done acutely the sedative hypnotic medications must be tapered slowly over several weeks.

Given orally or parenterally in severe cases.

Several months may be required for detoxification.

Diazepam
Oxazepam
Clorazepate
Thiamine
Phenytoin

Treatment of Acute Alcohol Poisoning

Important goals of treatment are to prevent respiratory depression and aspiration of vomitus.

Average blood concentration in fatal cases is 400 mg/L.

Patient may require gastric lavage and possibly hemodialysis & restoration of fluid and electrolyte balance.

Treatment of Metabolic acidosis and hypothermia

Hypoglycemia & acidosis should be treated with glucose.

USES OF ALCOHOL:

“They ask You concerning intoxicants and gambling,

Say, in them is great sin and some profit for men, But the sin is greater than the profit.”

(Holy Quran 2: 219)

One may wonder after all the above disadvantages can there be any use of drinking alcohol.

Well, there are some benefits but the disadvantages outweigh heavily its benefits as the Holy Quran states above.

1. Decreased Incidence of CHD, Stroke & PVD in people who drink low amounts of ethanol daily. Presumed mechanisms include:

Increase HDL
Inhibit inflammatory processes of atherosclerosis
Increase tPA
Anti-oxidants in alcholic drinks

As mentioned above moderate doses of alcohol increase HDL and decrease LDL and thus exert a protective against against atheroma formation.

And ethanol may also protect against ischemic heart disease by inhibiting platelet aggregation.

So the benefit is largely a reduction of deaths due to cardio and cerebrovascular disease for regular drinkers of 1-2 units / day for men over 40 and postmenopausal women.

But it is often very difficult to limit oneself to a single drink of alcohol per day due to its initial acute beneficial effects as mentioned above.

2. Alcohol may be used in the treatment of methanol poisoning as it competitively inhibits metabolism of methanol to the toxic formaldehyde and formic acid by the dehydrogenase (FOMEPIZOLE, alcohol dehydrogenase inhibitor, is approved for the treatment of METHANOL and ETHYLENE GLYCOL poisoning)

3. Ethanol is also used as an antiseptic or as a solvent for other drugs.

3. It is also used to harden the skin in bedridden patients.

4. Local application also reduces sweating and may allay itching.

5. Alcohol injections are sometimes used to destroy nervous tissue in cases of intractable pain (trigeminal neuralgia, carcinoma involving nerves)

6. Parenterally it was used to prevent premature abortion .

Drug Interactions of Alcohol

While performing activities requiring skill especially driving drugs like all cerebral depressants can potentiate or synergise with alcohol.

These include sedative hypnotics like benzodiazepines and barbiturates; tranquillizers, antihistamines, anti-epileptics, antidepressants and phenothiazines. Deaths have occurred from these combinations.

Alcohol also potentiates the pharmacological effects of many non-sedative drugs including vasodilators and oral hypoglycemic drugs.

Alcohol may also enhance the anti-platelet action of aspirin.

Since some ethanol is metabolized by the microsomal mixed function oxidase system ethanol also produces a dual effect on the metabolism of many other drugs metabolized by the mixed function oxidase system (e.g. phenothiazines, warfarin, and steroids) with an initial inhibitory effect produced by competition followed by enhancement due to enzyme induction.

The interaction with disulfiram has been discussed above. Many other drugs produce a similar effect e.g.