1. Alcohol

2. Plan Role play in small groups Discuss any issues which arise Go through some of the basics Cover the entire “journey”

3. Introduction 24 % of English population drink in a way which is potentially/actually harmful 4 % of English population are dependant Upper limits of alcohol –Men 21 units / week –Women 14 units / week

4. Calculating units 1 alcohol unit = 10 mls or 8 grams of pure alcohol 25mls single measure whiskey – 1/3 rd pint of beer – half a standard (175ml) glass of wine Strength (%) x Volume (mls) / 1000 = units

5. Definitions Hazardous –Pattern of alcohol drinking which increases risk of harm Harmful –Pattern of alcohol drinking which causes harm (mental or physical) Dependancy –Cluster of attributes including craving, tolerance, drinking in spite of harm and withdrawal symptoms

6. Screening Tools CAGE –Cut down –Annoyed –Guilty –Eye opener 2 or more significant Sensitivity 93%, Specificity 76% for identifying hazardous drinkers

7. Screening Tools AUDIT (alcohol use disorders identification test) –Developed by WHO –Pick up early signs of hazardous/harmful drinking –10 questions, score out of 40 –8 or more significant Sensitivity 92%, Specificity 94% for identifying hazardous drinkers Audit-C uses the first 3 questions only –4 or more significant

8. “Brief Interventions” An interaction lasting between 5 and 45 minutes, the principles of which are: –F: Feedback about personal risk –R: personal Responsibility –A: Advice to reduce or abstain –M: Menu of alternative options to change drinking pattern –E: Empathic interviewing, listen and explore –S: Self efficacy, enhance patien’s belief in their ability to change Works to reduce total alcohol consumption and episodes of binge drinking in Hazardous drinkers for up to 1 year (NNT = 8) Not so great for Harmful or Dependant drinkers

9. Management Local alcohol services –Phoenix Futures (Care Navigation, Widening Horizons, Treatment and Engagement) –Substance Mis-use team Detoxification: –Consider if consuming > 15 units alcohol/day or AUDIT score > 20 –Medication may not be necessary if consuming < 15 units/day (men) or < 10 units/day (women) and no recent withdrawal symps or drinking to suppress withdrawal symps Medications to prevent relapse

10. Detoxification Community or in-patient –No difference in success at rates at 6 months –Possible cost savings (for community) –Intoxicated patients presenting to GPs/OOHs/A+E requesting detoxification should be given written info re local services and advised to make “Primary care appt” In-patient detox would be advised if: –Previously complicated withdrawal –Hx of epilepsy/fits –Undernourished –Risk of suicide –Multiple substance misuse –Unwilling to be seen daily –Acute physical/psychiatric illness

11. Medication to prevent relapse 3 medications available: –Acamprosate, “modulates disturbance” in the GABA/Glutamate system, use for 6 – 12 months –Disulfiram, reacts with alcohol to induce vomiting –Naltrexone SIGN advise Acamprosate or Disulfiram NICE advise Acamprosate or Naltrexone

12. Alcoholic Liver Disease Caused by chronic heavy alcohol ingestion No test which can confirm alcohol as the cause of liver damage 3 stages: –Alcoholic fatty liver –Alcoholic hepatitis –Cirrhosis 90 – 100% “heavy” drinkers will have alcoholic fatty liver disease 25 % of those with fatty liver will develop alcoholic hepatitis 20 % of those with fatty liver will develop cirrhosis

13. Alcoholic Liver Disease Always important to rule out other conditions (ie viral hepatitis, auto-immune conditions, genetic conditions etc) AST > ALT ratio of 2:1 (in 70% of cases) Complications tend to arise from Portal Hypertension: –Variceal bleeding –Ascites –Coagulopathy –Hepatic encephalopathy Treatment: –Abstinence –Supportive ie medication, banding, diuretics, drainage of ascites, correcting electrolyte/coagulation disturbances etc –Liver transplant