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Alcohol Awareness: what every GP needs to know


Title: Substance Misuse Author: Deepika Yerrakalva Last modified by: Buch Wendy (RTR) South Tees NHS Trust Created Date: 8/11/2010 4:18:30 AM Document presentation format – PowerPoint PPT presentation

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Title: Alcohol Awareness: what every GP needs to know

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

  • Alcohol the acceptable drug?

  • 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
  • DoH Number of units - women/men
  • How to calculate?
  • What is the ABV
  • That is the number of units in 1 litre of that
  • 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

  • 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
  • Who regularly attend GUM clinics or request
    emergency contraception

Screening Tools
  • CAGE (cut-back, annoyed, guilty, eye-opener)
  • AUDIT (General Practice)
  • Paddington Alcohol Test (AE)
  • 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.
    sweating, tremor, nausea, vomiting, anxiety,
    insomnia, seizures, hallucinations, or delirium
  • 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 gt30u/day
  • withdrawal sx plus agitation, apprehension,
    confusion, disorientation time and place, visual
    and auditory hallucinations, insomnia, nausea,
    vomiting, motor uncoordination, paranoid
    ideation, fever

Wernickes 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 Korsakoffs 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

Whos 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

  • In-patient or community?

Inpatient Detoxification Principles
  • Are they intoxicated? Blood alcohol or
  • If acute presentation, could flexibly prescribe
    4hrly for 24-48hrs then reassess onto a reducing
  • SAD-Q useful to guide prescribing
  • Must use rating scale regularly CIWA-Ar
  • Look for signs of liver disease
  • Dont forget to check clotting, albumin as well
    as GGT for liver function

Chlordiazepoxide (Librium)
  • See photocopy for suggested regimes
  • Doses gt 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,
  • 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
  • Advice
  • 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!
  • OR