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, eye-opener) 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 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, pre-coma) 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 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! speedydeeps@gmail.com OR sarahstevens@doctors.org.uk