Acute and chronic effects, including overdose, from the use of - alcohol

Description

Acute: disinhibition, ataxia, dysarthria, nystagmus -> progressing to coma, resp depression at high levels
Chronic: dependence, tolerance, multi-organ damage - liver, pancreas, CNS, cardiovascular, malignancy risk
Overdose is rarely fatal from alcohol alone at typical binge levels, but combination with other CNS depressants (benzodiazepines, opioids) is dangerous

Leading preventable cause of disease burden in Australia among drug categories
Standard drinks framework (Australia: 10g ethanol/standard drink) underpins risk guidance
NHMRC guidelines: no more than 10 standard drinks/week and no more than 4 on any day, to reduce lifetime risk

Acute

GABA-A potentiation + NMDA (glutamate) antagonism -> generalised CNS depression
Hypoglycaemia risk - inhibits hepatic gluconeogenesis (glycogen stores can still be depleted, esp. in malnourished/chronic drinkers)

Chronic

Liver: steatosis -> alcoholic hepatitis -> fibrosis/cirrhosis (acetaldehyde-mediated hepatocyte injury, oxidative stress)
Pancreas: acute and chronic pancreatitis
CNS: Wernicke-Korsakoff (thiamine deficiency), cerebellar degeneration, peripheral neuropathy
Cardiovascular: dilated cardiomyopathy, atrial fibrillation ("holiday heart"), hypertension
Malignancy: oropharyngeal, oesophageal, liver, breast, colorectal - acetaldehyde is a Group 1 carcinogen

Acute intoxication - clinical + blood alcohol level correlates poorly with impairment in chronic drinkers (tolerance)
Screen for use disorder: AUDIT-C, or ask directly about quantity/frequency and dependence features (tolerance, withdrawal, loss of control)
Chronic use work-up: LFTs (AST:ALT >2 suggestive of alcoholic liver disease), GGT, MCV (raised - direct marrow toxicity), FBE, coagulation, ultrasound/fibroscan if liver disease suspected

Acute intoxication/overdose

Supportive - airway protection, monitor for hypoglycaemia, thiamine before any glucose if malnourished/chronic use suspected
Consider co-ingestants in any presentation with severe depression at only modest alcohol level

Chronic use / dependence

See substance-use-disorder note for withdrawal and relapse prevention management
Manage complications on their own merits (hepatology, cardiology, neurology referral as needed)

Depression, anxiety, other substance use disorders
Domestic violence, road trauma, falls
Fetal alcohol spectrum disorder with in-utero exposure - no safe level established in pregnancy

Dependence and organ damage are usually reversible in early stages with abstinence; cirrhosis, established cardiomyopathy, and Korsakoff amnesia are often not
Relapse is the norm rather than the exception - treat as a chronic relapsing condition, not a failure of willpower

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