Alcohol Awareness: what every GP needs to know

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. 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: 12-48 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 • Advice • 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 • Email us for further reading! • speedydeeps@gmail.com OR sarahstevens@doctors.org.uk