1. Alcohol Awareness: what every GP needs to know
Dr Sarah Stevens
Dr Deepika Yerrakalva
Specialty Registrars in Psychiatry
2011

2. Alcohol: the acceptable drug?

3. Outline Why even bother? Group work: Units and classification
Screening and history
Complications and vitamins
Detoxification
Primary care issues
CSA Role Play

4. 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

5. 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

6. Group Work

7. 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

8. Classification
Hazardous
Harmful
Dependent

9. 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

10. Screening Tools CAGE (cut-back, annoyed, guilty, eye-opener)
AUDIT (General Practice)
Paddington Alcohol Test (A&E)
SAD-Q (best for guiding detox)

11. 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.

12. 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)

13. Complications of withdrawal

14. Withdrawal Symptoms Early: peak at 12 hrs
Withdrawal fits: hrs, more likely if past hx or epilepsy; single, generalised, 30% followed by DTs…

15. 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

16. 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

17. 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)

18. Who’s at risk?
Malnutrition - weight loss, poorly kempt, history of poor oral intake
Previous complicated withdrawal
Medical co-morbidity
Very high alcohol intake

19. 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)

20. 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

21. Detoxification…
In-patient or community?

22. 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

23. 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

24. 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

25. Other Primary Care Issues
Referral to secondary services
Abstinence-promoting medication
Brief interventions

26. 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)

27. Acamprosate (Campral)
Modulates GABA and glutaminergic systems
Not metabolised by the liver
Dose: 2 tablets 3 times a day (666mg TDS)

28. Brief Interventions Structured Brief Advice: Feedback Responsibility
Menu of options
Empathy
Self-Efficacy
Extended Brief Interventions (Motivational Enhancement Therapy)

29. CSA Role Play Clinical Skills Assessment Exam 10 minute stations
Drugs and Alcohol are a clearly defined key area in the exam topics

30. 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
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