Transcript Alcohol Misuse

Alcohol & Drugs:
Timetable
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Do we know our units?
How might someone present with alcohol problems?
Management of alcohol misuse
Case discussions – small groups
TEA!
Drug history taking
How to recognise a patient with substance misuse
Management of benzodiazepine dependence
Local services & referral
Alcohol Misuse
By Mahya Mirfattahi
HDR LRCH
Wednesday 17th March
Learning Outcomes
• RCGP Curriculum Statement 15.3: Drug and Alcohol
Problems
• Manifestation of alcohol problems
• Health and social burden of excess alcohol consumption
• The use of screening tools for alcohol such as Cut down
Annoyed Guilty Eye-opener (CAGE) and Alcohol Use Disorders
Identification Test (AUDIT)
• The range of treatment interventions available including
pharmacological interventions
• The impact that health professionals can make by providing
brief intervention for excess alcohol use
• Alcohol-related emergencies
• Adopt a person-centred approach, whilst acknowledging the
conflicts between a perceived self-inflicted problem & a right to
evidence-based treatment
DOH Definitions
• Recommends use of terms
• Lower risk
– Implies that no level of alcohol consumption is
completely safe e.g. drinking & driving
• Increasing risk
– Regularly drinking >2-3 units/day women, >3-4
units/day men
• Higher risk
– Regularly drinking >6 units/day or 35 units/week
women, >8 units/day or >50 units/week men
Definitions
• Hazardous drinking
– Regular consumption above recommended daily
intake
– Men >5 units, women >3 units
– Pattern of drinking carries the risk of harm, but
have not yet experienced alcohol related problem
• Harmful drinking
– ICD-10 defines as pattern of drinking that causes
damage to physical or mental health
38 yr old, male
• Presents to you with symptoms of GORD
• You explore his lifestyle
• He drinks 4 pints/night most days of week, on
Saturday nights he goes out with the lads &
cannot tell you how much he has
• Some mornings he notices a tremor & has
sweats
• He tells you he has difficulty in sleeping
• He is also having relationship problems
• He has called in sick at work on a few
occasions
Alcohol Dependence
• Cluster of psychological,
behavioural and cognitive
symptoms
• 3 or more of the following
experienced together in
last 12 months
• Relatively small group
compared to lower,
increasing or higher risk
drinkers = 3% population
Alcohol Dependence ICD-10
• Compulsion – strong desire or sense of compulsion to take
alcohol
• Loss of control – difficulties in controlling drinking in terms of
onset, termination or levels of use
• Withdrawal – physiological state in response to cessation or
reduction of use, or drinking to relieve or avoid withdrawal
symptoms
• Tolerance – increased doses required to achieve effects
originally produced by lower doses
• Pre-occupation with alcohol – progressive neglect of
alternative pleasures or interests, or increased amount of time to
obtain or take alcohol, or recover from its effects
• Persistent use – continued use despite evidence of harmful
consequences
World’s first wine
• Ancient Persian fable
• A princess having lost favour with the King
attempts to poison herself by eating a jar of
“spoiled” grapes. She became intoxicated &
giddy & fell asleep. When she woke up she
found the stressors that made her life so
intolerable dispersed. Her subsequent
conduct changed so remarkably that she
regained the King’s favour. He shared his
daughter’s discovery with his court & decreed
an increase production of “spoiled” grapes
The evidence…
• Jar one of six vessels found at
Neolithic village site in Iran
• Remains of a 7,000 year old wine
• Chemical tests show evidence of
grape & resin from a tree used as
a preservative showing that wine
was deliberately made & not just
unintentional fermentation of
grapes
• http://www.archaeology.org/9609/
newsbriefs/wine.html
Identification & Brief Advice
• IBA pathway
– Initial Screening to identify whether an
individual is drinking above lower risk
levels
– Full Identification to define level of risk
– Brief Advice & Referral if necessary
Screening Tools
• CAGE
• Have you ever felt you should Cut down on your
drinking?
• Have people Annoyed you by criticizing your
drinking?
• Have you ever felt bad or Guilty about your drinking?
• Have you ever had a drink first thing in the morning to
steady your nerves of get rid of a hangover? (Eyeopener)
AUDIT
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High sensitivity 92% & specificity 94%
10 questions
Detects all types of alcohol misuse
Scores >20 possible dependence
Too time consuming, therefore shorter
versions used as pre-screen have
similar validity & reliability
AUDIT-C
• 3 questions from AUDIT
• Short
• Indicates whether an individual is
potentially drinking at increasing or
higher risk levels
• Does not detect alcohol dependence
AUDIT-PC
• For use in primary care
• 5 questions
• Identifies increasing or higher risk levels
Brief Advice
• Is the patient willing to change?
• Use Readiness Ruler
• On a scale of 1-10 “How important is it
for you to change your drinking?”
• Useful framework is stages of change
model
Elements of Brief
Interventions
• For hazardous or harmful drinker willing to change
• Feedback – present screening results
• Responsibility – emphasis on personal responsibility
for change
• Advice – to cut down or abstain
• Menu – options for changing drinking pattern, jointly
with patient establishing goal(s)
• Empathic interviewing – active listening, without
confrontation, exploring with patients reasons for
change
• Self efficacy – encouragement
In practise…
• Some statement to prepare the patient for
intervention
• Give patient leaflet
• List common effects of drinking
• Give feedback on other people
• Provide information – point out benefits of
cutting down
• Establish a goal
• Explain units & give advice on limits
• Provide encouragement
Video
For video link go to
http://www.alcohollearningcentre.org.uk/Topics/Latest/
Resource/?cid=5059
Detoxification
• Alcohol dependence
• Increasing or higher risk drinker who has not
responded to previous brief intervention
• If the drinker wants to stop drinking refer to
community alcohol team for support &
treatment
• Involve family & friends
• Give general advice
• Drinkers should set a ‘stop drinking’ date
• Stress that medication does not stop urge but
reduces withdrawal symptoms
Community Detoxification
• Usually uses a reducing regimen of
chlordiazepoxide over a week long period
• Referral to CAT
– For Derbyshire county this is 01773 829966
– For Derby City: Bradshaw Clinic, 1 Charnwood St, Derby
01332 221700
– Addaction
• Frequent follow-up by CAT worker
• Ensure patient is taking thiamine
supplements 200mg daily for at least duration
of detoxification
54 yr old, male
• You have arranged follow-up as he is
undergoing community detoxification
• As he walks into the consultation room
you notice he is unsteady
• On questioning he appears confused
• He cannot remember the events the
previous day
• What are you worried about?
Wernicke-Korsakov Syndrome
• Any sign of Wernicke-Korsakov’s patients
should receive Pabrinex in a setting with
appropriate resuscitation facilities
• Signs: confusion, ataxia (truncal),
ophthalmoplegia, nystagmus, memory
disturbance, hypothermia, hypotension, coma
• Should continue over several days ideally in
an inpatient setting
• In the community patients at risk of WernickeKorsakov’s should be given intramuscular
Pabrinex
Inpatient Detoxification
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Confusion or hallucinations
History of previously complicated withdrawal
Epilepsy or history of fits
Malnourishment
Severe vomiting or diarrhoea
Is at risk of suicide
Has severe dependence coupled with poor cooperation
Failed detoxification at home
Uncontrollable withdrawal symptoms
Acute physical or psychiatric illness
Multiple substance misuse
Poor home environment unsupportive of abstinence
26 yr old, female
• Decides to abstain from alcohol
• She normally drinks 3-4 glasses of wine/day
• Her flat mate calls the surgery asking for a
home visit as she is worried about her
• She feels hot, sweaty, palpitations, doesn’t
know where she is, seems to be drifting in &
out of consciousness, claims she can see
things that aren’t there like crawling insects
• What are you worried about?
Medications to prevent
relapse
• Acamprosate
– Enhances GABA transmission & inhibits glutamate
– Reduces craving in postwithdrawal period
– Should be prescribed for min. 12 months
• Disulfiram (Antabuse)
– Deters patients from resuming drinking
– Unpleasant reaction – blocks metabolism of
alcohol
– Can be dangerous
– Minimum of 6 months
Follow-up & support groups
• Patient motivation
• Self-help & support groups
– Alcoholics Anonymous www.alcoholicsanonymous.org.uk
– www.al-anon.org.uk
– Drink aware www.drinkaware.co.uk
– Alcohol concern www.alcoholconcern.org.uk
• Encourage to contact GP if relapse occurs
• Patients need to know that if they relapse
there are still support strategies in place
Happy
St Patrick’s Day!
Resources
• Bolland, W. (2008) Alcohol and primary care.
InnovAiT. 1 (2) 141-149
• Patel, I. (2010) Alcohol and depression. InnvoAiT. 3
(3). 155-165
• www.alcohollearningcentre.org.uk
• Clinical Knowledge Summaries. Alcohol – problem
drinking. Accessed via
www.cks.nhs.uk/alcohol_problem_drinking
• Scottish Intercollegiate Guidelines Network (SIGN)
The Management of Harmful Drinking and Alcohol
Dependence in Primary Care (2003) Available from
www.sign.ac.uk/sign74.pdf