Transcript Substance Misuse - Northallerton VTS

Alcohol Awareness:
what every GP needs to know
Dr Sarah Stevens
Dr Deepika Yerrakalva
Specialty Registrars in Psychiatry
2011
Alcohol: the acceptable drug?
Outline
Why even bother?
Group work:
– Units and classification
– Screening and history
– Complications and vitamins
– Detoxification
Primary care issues
CSA Role Play
Why bother?
Is the 5th commonest disease burden in the
world
Overall, alcohol is estimated to cause a net
harm of 4.4% of the global burden of disease
Alcohol-related harm is estimated to cost
society between £17.7 billion and £25.1
billion per year
£2.7 billion a year to treat the chronic and
acute effects of drinking
Why bother?
15-30% of patients seen in GP or hospital settings
have an underlying alcohol use disorder
Less than 1/3 are diagnosed
up to 35% of all emergency department attendances
and ambulance costs are alcohol-related
In 2007/08 there were 863,300 alcohol- related
admissions, a 69% increase since 2002/03
Group Work
Units
DoH Number of units - women/men
How to calculate?
– What is the ABV %
– That is the number of units in 1 litre of that
drink
– Work out the proportion
– E.g. wine is about 12% ABV, so 1litre of it
contains 12 units, so a 750ml bottle contains
approx 9 units
Classification
Hazardous
Harmful
Dependent
Who should we screen?
People at increased risk of harm
– With relevant physical conditions (such as hypertension and
GI liver disorders)
– With relevant mental health problems
– Who have been assaulted
– At risk of self-harm
– Who regularly experience accidents or minor traumas
– Who regularly attend GUM clinics or request emergency
contraception
Screening Tools
CAGE (cut-back, annoyed, guilty, eyeopener)
AUDIT (General Practice)
Paddington Alcohol Test (A&E)
SAD-Q (best for guiding detox)
Brief Alcohol History
Consumption of units per day/week
Drinking pattern daily/continuous or
episodic/binge drinking
Drinking behaviour in the past week/6
months
When did they have their last drink?
History of alcohol-related problems:
medical, psychiatric, social, relationships,
occupational, financial, legal etc.
Is there a history of withdrawal symptoms, e.g.
sweating, tremor, nausea, vomiting, anxiety,
insomnia, seizures, hallucinations, or delirium
tremens?
Is there a history of morning/relief drinking,
change in tolerance, strong compulsion to drink,
continued drinking despite problems, priority of
drinking over other important pursuits/activities,
unable to control drinking? (evidence of dependence
syndrome)
Complications of withdrawal
Withdrawal Symptoms
Early: peak at 12 hrs
Withdrawal fits: 12-48 hrs, more likely if
past hx or epilepsy; single, generalised, 30%
followed by DTs…
Delirium Tremens
5% of withdrawal episodes
within hrs: peak 48hrs,
subsides over 3-4 days
esp if >30u/day
withdrawal sx plus
agitation, apprehension,
confusion, disorientation
time and place, visual and
auditory hallucinations,
insomnia, nausea, vomiting,
motor uncoordination,
paranoid ideation, fever
Wernicke’s Encephalopathy
Acute neuropsychiatric condition: initially
reversible biochemical brain lesion caused by
overwhelming metabolic demands on cells with
depleted intracellular thiamine (vitamin B1)
Can progress to irreversible structural brain change
Korsakoff’s Psychosis: short-term memory loss and
impairment of ability to acquire new information,
needing long term institutional care
– Classic triad: confusion (82%), ataxia (23%),
opthalmoplegia (29%) (only 10% all three)
– Other signs (acute mental impairment, precoma) easily misattributed to intoxication,
withdrawal itself or concurrent morbidity such
as head injury)
Who’s at risk?
Malnutrition - weight loss, poorly
kempt, history of poor oral intake
Previous complicated withdrawal
Medical co-morbidity
Very high alcohol intake
Always take your vitamins!
During alcohol withdrawal, there is an increased
demand on already depleted thiamine
PABRINEX: thiamine (B1), riboflavin (B2),
pyridoxine (B6) and nicotinamide
IV and IM preparations (the IM has benzyl alcohol as
local anaesthetic)
Anaphylaxis risk is low; 4/million pairs IV, 1 per 5
million pairs IM (but observe 15-30min)
If have WE: give treatment doses 2 pairs (I
and II) IM or IV TDS for 3 days
Check serum magnesium
If at risk of WE: give prophylactic 1 pair (I
and II) OD for 5 days
Thereafter oral Vitamin B Co-strong 2 tabs
TDS for 6 weeks
See Royal College of Physicians
recommendations
Detoxification…
In-patient or
community?
Inpatient Detoxification:
Principles
Are they intoxicated? Blood alcohol or
breathalyser
If acute presentation, could flexibly
prescribe 4hrly for 24-48hrs then reassess
onto a reducing regime
SAD-Q useful to guide prescribing
Must use rating scale regularly CIWA-Ar
Look for signs of liver disease
Don’t forget to check clotting, albumin as
well as GGT for liver function
Chlordiazepoxide (Librium)
See photocopy for suggested regimes
Doses > 100mg daily are above BNF
guidelines so discuss with senior first
Rarely px 40mg QDS in women, never in
elderly or liver impairment
Elderly should have 50% less than stated
Small PRN doses for first 48hrs, but reassess
If liver impairment, use oxazepam or
lorazepam
Community detox: principles
Preparation for detox
enhance motivation
plan post-detox activities/support
Daily assessments for first 3 days: CIWAS!
Prescribe according to symptoms
Vitamins (IM?)
Relapse prevention, AA, specialist groups
Medications
Other Primary Care Issues
Referral to secondary services
Abstinence-promoting medication
Brief interventions
Abstinence Promoting
Medications
Disulfiram (Antabuse)
– Inhibits hepatic aldehyde dehydrogenase
– DER: flushing, abdo pain, anxiety, palpitations,
death
– Contra-indications: hypertension, liver disease,
ischaemic heart disease
– Educate patient, safety card
– Need baseline LFTs, check at regular intervals
– Supervision of medication (evidence base)
Acamprosate (Campral)
– Modulates GABA and glutaminergic
systems
– Not metabolised by the liver
– Dose: 2 tablets 3 times a day (666mg TDS)
Brief Interventions
Structured Brief Advice:
– Feedback
– Responsibility
– Advice
– Menu of options
– Empathy
– Self-Efficacy
Extended Brief Interventions (Motivational
Enhancement Therapy)
CSA Role Play
Clinical Skills
Assessment Exam
10 minute stations
Drugs and Alcohol
are a clearly
defined key area in
the exam topics
In summary...
THINK ABOUT ALCOHOL! Always ask and assess.
Rating scales
Safe and adequate alcohol detoxification, inc
adequate vitamin replacement
Find out about your local alcohol and drug services
and signpost your patients
Brief interventions
Email us for further reading!
[email protected] OR [email protected]