Transcript Alcohol

The GP curriculum states that
GPs in training must:
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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?
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Alcohol Misuse
 Very broad term referring to any alcohol use likely to result
in problems
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Binge Drinking
 Consuming more than the recommended DAILY
allowance of alcohol
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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
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Health Effects of Alcohol misuse
Injury – fights or accidents
 Increased cardiovascular morbidity
 Multiple gastrointestinal morbidities:
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 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
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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:
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Screening for Alcohol Misuse
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Traditional signs
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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
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 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)?
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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!
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Intervention!
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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
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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
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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.
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Simple advice
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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
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Contraindications to home detox
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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
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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.
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Delirium Tremens
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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
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Wernicke’s/Korsokoff’s
Caused by thiamine deficiency
 Wernicke’s is a reversible encephalopathy
characterised by:
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Acute confusional state
Opthaloplegia
Ataxia
Peripheral neuropathy
Untreated, will progress to irreversible
Korsokoff’s psychosis:
 Antero & retrograde amnesia
 Confabulation
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