Transcript Alcohol
The GP curriculum states that
GPs in training must:
Understand the health and social burden of
excess alcohol consumption to the patient, the
patient's family and the wider community
Be able to recognize the physical, psychological
and social manifestations of alcohol problems
Be able to use screening tools to detect and
assess alcohol problems in the practice
populations
Be able to use brief interventions to assist
patients consuming harmful amounts of alcohol to
recognize that a problem exists, and cut down or
stop drinking
Be able to recognize and manage alcohol-related
emergencies such as fits, delirium and psychosis.
How is consumption categorised?
Alcohol Misuse
Very broad term referring to any alcohol use likely to result
in problems
Binge Drinking
Consuming more than the recommended DAILY
allowance of alcohol
Alcohol Dependence
Syndrome with specific symptoms. Must include three of
the following:
○ Compulsion
○ Loss of control
○ Withdrawal
○ Preoccupation with alcohol
○ Persistent drinking
○ Tolerance
The Burden of Alcohol
259 million primary care consultations/year
150,000 hospital admissions
15,000 to 22,000 deaths, mainly comprising
stroke, liver failure, cancer and suicide
Half of all violent crime
1/3 of all domestic violence
17 million sick days
Cost to the NHS: £1.7 billion
Total cost to economy £2.4 billion
Total revenue from duties... £13.3 billion
Health Effects of Alcohol misuse
Injury – fights or accidents
Increased cardiovascular morbidity
Multiple gastrointestinal morbidities:
Liver damage – fatty liver, cirrhosis, failure
Gastritis and oesphagitis
Acute and chronic pancreatitis
Anxiety & Depression, Dementia
Diabetes & Macrocytic anaemia
Sexual dysfunction
Encephalopathy – Wernicke’s & Korsokoff’s
Effects of high-risk drinking
bolland, W. InnovAiT 2008 1:141-149; doi:10.1093/innovait/inn006
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Social Effects of Alcohol Misuse
Relationship breakdown
Social Isolation worsening MH problems
Loss of employment, financial instability,
homelessness
Stress on family, friends, partners, leading to
their own health and social consequences
Motor accidents, loss of licence, DVLA
intervention:
Screening for Alcohol Misuse
Traditional signs
Smell on breath
Tremor – hands, legs, tongue
Bloodshot eyes & dilated facial capillaries
GI tract disorders
Frequent accidents
Insomnia, anxiety, depression
Social problems
Unexpected abnormal test results
Formal screening tools
CAGE
AUDIT
CAGE
Have you ever felt you should Cut down
on your drinking?
Have people Annoyed you by criticizing
your drinking?
Have you ever felt bad or Guilty about
your drinking?
Have you ever had a drink first thing in
the morning to steady your nerves or get
rid of a hangover (Eye-opener)?
AUDIT – Alcohol Use Disorders
Identification Test
A tool to assess severity of drinking problem and
the best method for treatment.
Not technically a screen
10 questions with
answers scoring 0-4,
severity of drinking and
appropriate treatment
course based on score
Feel free to score
yourself!
Intervention!
Practices can provide specialist care as a NES (£££).
To do this, they must:
Provide training for team members involved
Routinely use alcoholism assessment tools
Develop a register of all patients who admit that they are
alcohol misusers
Undertake brief interventions and offer support to carry out
behavioural change
Provide detoxification in the community or home setting
Arrange follow-up treatment which might include counselling
services (in conjunction with or by referral to the local alcohol
services) or referral to a day programme or alcohol
rehabilitation centre
Liaise with local specialist alcohol treatment services
Perform an annual review of the service including audit.
Alcohol education
Tell patient about risks of alcohol
Explain nationally accepted limits of safe
alcohol use
Advise not to use alcohol at all when
driving or operating heavy machinery
Readiness to Change
A simple question to ask patients – ‘on a
scale of 1-10, how important is it to you
to change your drinking’
1-4 indicates pre-contemplative
5-6 indicates thinking about change
7-10 suggests patient ready to take
action.
Simple advice
Feedback—structured and personalized feedback
on risk and harm.
Responsibility—emphasis on patient's personal
responsibility for change.
Advice—Clear advice that change is needed.
Menu—A menu for alternative strategies for making
a change in behaviour.
Empathetic—delivered in an empathetic, nonjudgemental fashion.
Self-efficacy—An attempt to increase the patient's
confidence in being able to change behaviour.
Alcohol Dependant Drinkers
Stopping immediately may be harmful and
should not be advised
Prescribe vitamins – thiamine and folate
If a patient wants to stop drinking, referral to
the community alcohol team is indicated
Home detoxification without alcohol team
support is not recommended
Contraindications to home detox
Confusion or hallucinations
History of previously complicated withdrawal (for example
withdrawal seizures or delirium tremens)
Epilepsy or fits
Malnourishment
Severe vomiting or diarrhoea
Increased risk of suicide
Poor co-operation
Failed detoxification at home
Uncontrollable withdrawal symptoms
Acute physical or psychiatric illness
Multiple substance misuse
Poor home environment
Alcohol Related Emergencies
Three main ones you need to know:
Fits
Delirium Tremens
Wernicke’s/Korsakoff’s
Fits
Can happen due to excessive drinking but
more commonly associated with withdrawal
Acutely need to be managed as any fit
Patients who experience fits due to withdrawal
should be managed in an inpatient settling,
whereas those who are continuing to drink
can be managed as an OP once other causes
are excluded.
Delirium Tremens
Syndrome characterised by the following:
Delirium, often worse at night
Clouding of consciousness; disorientation
Agitation
Hallucinations – typically visual, often frightening
Autonomic dysfunction – hypertension, fever etc
15% mortality rate
Treatment of choice - Benzos
Wernicke’s/Korsokoff’s
Caused by thiamine deficiency
Wernicke’s is a reversible encephalopathy
characterised by:
Acute confusional state
Opthaloplegia
Ataxia
Peripheral neuropathy
Untreated, will progress to irreversible
Korsokoff’s psychosis:
Antero & retrograde amnesia
Confabulation
Thanks for Listening!