Alcohol

One of our most common beverages, particularly on a special occasion, but what harm does this do to our health?

What is alcohol?

Alcohol or ethanol to be more specific, is a small molecule that is ingested, typically in beverages or some foods, and is absorbed into the blood stream through the lining of the stomach (20%) or small intestine (80%). Ethanol is able to dissolve in both fat and water, meaning that it’s can spread through the whole body and work effectively on the fatty tissue of the brain, exhibiting a primarily inhibitory effect on all the cells it meets. The presence of food in the stomach and small intestine can dilute the alcohol, increasing the time it takes for it to be absorbed. Low concentration drinks are absorbed slower as they are more diluted, while higher concentrations work faster.

alcoholmetabolism

Alcohol is broken down in the liver by alcohol dehydrogenase (ADH) into acetaldehyde, which is then metabolised into acetate by acetaldehyde dehydrogenase (ALDH). ADH is a toxic molecule that when it accumulates, makes the person feel sick. Continuous drinking increases the number of these enzymes present in the liver, metabolising alcohol faster, but can also affect diabetic and blood clotting medications, reducing their effectiveness. Another effect of this tolerance can result in the person becoming tolerant to other medications, even if they haven’t been previously exposed (Kuhn et al., 2014).

How many people are drinking?

The UK currently rocks in as the 18th country in the world with the highest number of drinkers. 58% of people in the UK admit to drinking in the last week, with the majority of these people being in the higher wage brackets (£40,000+), while lower earners drink less. Men are more likely to drink than women, and 31% of men and 16% of women are drinking harmful quantities of alcohol. It’s also not just adults, 73% of 15-year old’s have had a drink, with the majority of the alcohol coming from their parents or friends. Children who live with adults who drink regularly are more likely to drink themselves and Cornwall currently has the third highest prevalence for underage drinking in the UK (NHS Digital, 2018). An estimated 9% of men and 3% of women are dependent on alcohol, with the majority of these people living in areas of increased social deprivation (HSCIC, 2015).

Alcoholics

Alcoholism is characterised as a chronic relapsing condition that can have serious detrimental effects on a person’s health. It typically develops as a cycle of positive and negative reinforcement, with alcohol induced euphoria alleviating other mental and physical symptoms. As drinking increases, the person will become more tolerant, requiring higher doses. Withdrawal from alcohol can lead to seizures, convulsions, motor abnormalities, autonomic disturbances and anxiety (Gilpin and Koob, 2008).

Long term exposure to alcohol can lead to permanent damage to the brain, shrinking its overall size and damaging cells within the frontal lobe, an area of the brain responsible for executive function and the mammillary bodies, a section responsible for memories. The main areas that are compromised by chronic alcoholism are abstract thinking, memory formation, problem solving, concentration and emotional perception (Kuhn et al., 2014).

Hospital admissions

In 2016, 337,000 admissions to hospital were related to alcohol with 62% of these admissions being for people aged between 45-54 years of age. A quarter of these are due to alcohol related cancers, 22% due to alcohol related injuries with mental and behavioural disorders, cardiovascular disease and liver disease following closely behind. Cornwall alone saw 4,270 admissions in 2017 due to alcohol use, with twice the number of men than women coming in (NHS Digital, 2018).

Deaths

Alcohol is still a leading risk factor associated with premature disability and death with 3.3 million people dying worldwide. In 2017 5,507 deaths in the UK were directly linked to alcohol, a higher number of these being in the north of the UK and is associated with higher levels of social deprivation (Nalini et al., 2018; NHS Digital, 2018). It also accounts for 13.5% of deaths in 20-39 year old’s around the world, being the leading cause in this age group (WHO, 2018).

Associated medical conditions – just a few

Cancers – liver, stomach, bowel, oesophageal.
Liver cirrhosis
Pancreatitis
Cardiomyopathy and ischaemic heart disease
Both ischaemic and haemorrhagic strokes
Alcohol induced dementia
Erectile dysfunction and decreased sperm production (Shield, Parry and Rehm, 2013; Kuhn et al., 2014)

Interactions with other medication

Sedatives or anti-anxiety medications – these can further depress the central nervous system,  causing anything from impaired decision making to coma and death.

Anti-coagulants – in non-chronic drinkers, alcohol increases the function of anticoagulants by improving their bioavailability; chronic drinkers actually have decreased effect due to changes in liver enzyme numbers.

Antibiotics – some can interact with alcohol, leading to nausea, sickness and seizures.

There is an even longer list of medications that interact with alcohol and patients should be advised to consult with their doctor/non-medical prescriber as there is a vast variability in the impact of alcohol on these drugs (Kuhn et al., 2014).

Treatment

Those patients who are dependent on alcohol will need assistance in withdrawal as the side-effects of this process can be significant, including risk of seizures. This process is called a detox and can either be done at home or in a hospital; this can depend on a number of factors, including level of dependence, previous experiences or risk of seizures. In chronic drinkers, the inhibitory effect of the ethanol on the brain increases the action of the neurotransmitter GABA, an inhibitory molecule, while at the same time suppressing glutamate, an excitatory neurotransmitter. When the person then goes to stop drinking, this upsets the ‘abnormal’ homeostasis of the brain, leading to excess excitation, causing seizures. Medications such as chlordiazepoxide are used to help relax the patient as well as reduce the incidence of seizures (Hoffman and Weinhouse, 2017).

Medications to help withdrawal

Acamprosate – effects levels of GABA within the brain, helping reduce cravings.

Disulfiram – allows concentrations of acetaldehyde to build up within the body, making drinking alcohol and taking the medication very unpleasant.

The NHS currently spends £4.42 millions on these prescriptions, and this doesn’t include any other medications related to alcohol induced disease or vitamin deficiencies (NHS Digital, 2018).

So what?

At some point in a nurses career, they will meet someone that struggles with alcohol, whether they are a bit more than casual drinker, or a full blown alcoholic. Part of the nursing role is to support patients with their illness, whether this be mental or physical, ensuring that they are as fully informed as possible about conditions and medications. Highlighting risks to patients may be enough to get them thinking about their drink use, or they may want to be referred onto other services for further help. It may be that we have to acknowledge that they don’t wish to alter their behaviour and then we must support them with this decision without judgement, helping them to remain as safe as possible.

It’s also important to remember that all of the facts and figures above come primarily from surveys or hospital admission records and are likely to be a gross underestimate of the real number of people effected by alcohol.

More information

https://www.drinkaware.co.uk/alcohol-support-services/

https://www.addaction.org.uk/services/addaction-truro

References

Gilpin, N. W. and Koob, G. F. (2008) ‘Neurobiology of alcohol dependence: focus on motivational mechanisms.’, Alcohol research & health : the journal of the National Institute on Alcohol Abuse and Alcoholism, 31(3), pp. 185–95. Available at: http://www.ncbi.nlm.nih.gov/pubmed/19881886 (Accessed: 28 November 2018).

Hoffman, R. and Weinhouse, G. (2017) Management of moderate and severe alcohol withdrawal syndromes, UpToDate. Available at: https://www.uptodate.com/contents/management-of-moderate-and-severe-alcohol-withdrawal-syndromes (Accessed: 3 December 2018).

HSCIC (2015) Statistics on Alcohol. Available at: http://www.hscic.gov.uk (Accessed: 28 November 2018).

Kuhn, C. et al. (2014) Buzzed : the straight facts about the most used and abused drugs from alcohol to ecstasy. New York: W. W. Norton & Company.

Nalini, M. et al. (2018) ‘Causes of premature death and their associated risk factors in the Golestan Cohort Study, Iran.’, BMJ open, 8(7), p. e021479. doi: 10.1136/bmjopen-2018-021479.

NHS (2018) Alcohol misuse – Treatment, NHS. Available at: https://www.nhs.uk/conditions/alcohol-misuse/treatment/ (Accessed: 3 December 2018).

NHS Digital (2018) Statistics on Alchol 2018. Available at: http://www.statisticsauthority.gov.uk/assessment/code- (Accessed: 27 November 2018).

WHO (2018) Alcohol. Available at: http://www.who.int/news-room/fact-sheets/detail/alcohol (Accessed: 28 November 2018).

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