1. Medicines that interact with alcohol See “Guidance on the administration of medicines to inpatients believed to have consumed alcohol ”

2. Any situation where a service user is found to be misusing substances (includes alcohol in excess), whilst in hospital must be treated individually. Baseline observations of pulse, blood pressure, respiration, levels of consciousness, arousal and pupil size must be taken and recorded. Medical staff and shift coordinator should agree what actions need to be taken and the frequency of physical observation. Administering medicines to patients believed to have consumed alcohol

3. Two factors will help influence the decision whether to omit or administer medication to a patient who is believed to be intoxicated: The Alcometer reading The nature of the medicine to be administered (its potential to interact with alcohol) Administering medicines to patients believed to have consumed alcohol

4. Alcometer Reading (breath alcohol) Comment / Suggested Course of Action Zero Administer all medication due, unless there are other clinical reasons not to do so. 0-0.15mg/L Administer all medication due, unless there are other clinical reasons not to do so. Consider whether prescribed regular sedatives / hypnotics are required if patient is already sedated or asleep. 0.16-0.35mg/L (0.35mg/L is the UK drink drive limit) Medication may be given following clinical assessment and discussion with a doctor. It is possible that prescribed regular sedatives / hypnotics may not be required. 0.36-0.8mg/L Medication may only be given following clinical assessment and discussion with a doctor. Above 0.8mg/L No medication to be administered

5. Medicines that interact with alcohol Disulfiram Sedating medicines Bupropion Antidiabetic drugs Antihypertensives Warfarin Other– Cocaine, methotrexate, aspirin and NSAIDs

6. Disulfiram like reactions Disulfiram used in relapse prevention in alcohol dependence Disulfiram like reaction also seen with other medicines e.g. metronidazole and levamisole Flushing, sweating, palpitations, hyperventilation, increased pulse, hypotension, nausea and vomiting Reaction occurs within 5-15mins and can be fatal

7. Sedative Medications Alcohol can increase the sedative effects of the following: Antidepressants e.g. tricyclic antidepressants, trazodone and mirtazapine. MAOIs such as tranylcypromine (hypertensive crisis) Antipsychotics e.g. clozapine and olanzapine Benzodiazepines and hypnotics e.g. diazepam and promethazine Medicines used in substance dependence and analgesia e.g. methadone, buprenorphine and morphine Antiepileptics e.g. sodium valproate or Depakote

8. Bupropion Bupropion (used for smoking cessation) is associated with a dose-dependant increased risk of seizures. Bupropion is contraindicated in patients who, at any time during treatment, are undergoing abrupt withdrawal from alcohol.

9. Antidiabetics There have been reports of hypoglycaemia caused by acute alcohol consumption in the general population. This is of particular concern in diabetic patients. Diabetic patients are advised to monitor blood glucose levels especially those taking any diabetic medication (in particular glibenclamide and gliclazide). Gliclazide and glibenclamide can also cause a disulfiram like reaction.

10. Antihypertensives Alcohol reduces blood pressure. This is of particular significance in patients already prescribed antihypertensive drugs (e.g. beta blockers) or vasodilatory drugs (e.g. nitrates or GTN spray).

11. Warfarin Occasional reports of increased INR in patients consuming alcohol and prescribed warfarin. Also binge drinking in those with liver disease can cause fluctuations in the prothrombin time and affect warfarin levels. Seek medical advice before with-holding warfarin treatment.

12. Other Examples Cocaine- Alcohol increases the levels of cocaine leading to an increased heart rate and blood pressure. The combination of alcohol and cocaine also causes cocaethylene to be formed that is longer acting and has a potentially damaging effect on the heart and liver. Methotrexate- There is some evidence to suggest that alcohol may increase the risk of methotrexate induced hepatic cirrhosis and fibrosis. Aspirin and NSAIDs- Alcohol may increase the risk of gastrointestinal haemorrhage associated with NSAIDs such as ibuprofen.

13. Case example 1 A patient is taking methadone oral solution on the ward and returns from leave the next day apparently still affected by alcohol from a party last night. He is prescribed 90ml methadone 1mg/ml and 10mg diazepam for this morning. What would you do?

14. Case example 1 – Answer Check alcometer reading and if it is above 0.35mg/L then withhold the methadone and diazepam. Tell the patient once the reading has reduced you will give them the methadone and/or diazepam if they appear to be physically stable and it is appropriate.

15. Case example 2 You see a patient in the community who is known to binge drink alcohol. She appears drunk and you do not have access to an alcometer. She is due 250mg clozapine this morning and 250mg tonight. What would you do?

16. Case example 2 – Answer Check Baseline observations of pulse, blood pressure, respiration, levels of consciousness, arousal and pupil size. Consider delaying the dose and inform the prescriber.

17. Case example 3 Would you administer a antipsychotic depot injection to a patient who is apparently drunk?

18. Case example 3 – Answer Check baseline observations of pulse, blood pressure, respiration, levels of consciousness, arousal and pupil size. Consider delaying the dose and inform the prescriber.