Alcohol

Plan

• Role play in small groups

• Discuss any issues which arise

• Go through some of the basics

• Cover the entire “journey”

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

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

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

Screening Tools• CAGE

– Cut down– Annoyed– Guilty– Eye opener

• 2 or more significant

• Sensitivity 93%, Specificity 76% for identifying hazardous drinkers

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

“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

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

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

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

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

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