1. Alcohol & Drugs: Timetable Do we know our units? How might someone present with alcohol problems? Management of alcohol misuse Case discussions – small groups TEA! Drug history taking How to recognise a patient with substance misuse Management of benzodiazepine dependence Local services & referral

2. Alcohol Misuse By Mahya Mirfattahi HDR LRCH Wednesday 17 th March

3. Learning Outcomes RCGP Curriculum Statement 15.3: Drug and Alcohol Problems Manifestation of alcohol problems Health and social burden of excess alcohol consumption The use of screening tools for alcohol such as Cut down Annoyed Guilty Eye-opener (CAGE) and Alcohol Use Disorders Identification Test (AUDIT) The range of treatment interventions available including pharmacological interventions The impact that health professionals can make by providing brief intervention for excess alcohol use Alcohol-related emergencies Adopt a person-centred approach, whilst acknowledging the conflicts between a perceived self-inflicted problem & a right to evidence-based treatment

4. DOH Definitions Recommends use of terms Lower risk –Implies that no level of alcohol consumption is completely safe e.g. drinking & driving Increasing risk –Regularly drinking >2-3 units/day women, >3-4 units/day men Higher risk –Regularly drinking >6 units/day or 35 units/week women, >8 units/day or >50 units/week men

5. Definitions Hazardous drinking –Regular consumption above recommended daily intake –Men >5 units, women >3 units –Pattern of drinking carries the risk of harm, but have not yet experienced alcohol related problem Harmful drinking –ICD-10 defines as pattern of drinking that causes damage to physical or mental health

6. 38 yr old, male Presents to you with symptoms of GORD You explore his lifestyle He drinks 4 pints/night most days of week, on Saturday nights he goes out with the lads & cannot tell you how much he has Some mornings he notices a tremor & has sweats He tells you he has difficulty in sleeping He is also having relationship problems He has called in sick at work on a few occasions

7. Alcohol Dependence Cluster of psychological, behavioural and cognitive symptoms 3 or more of the following experienced together in last 12 months Relatively small group compared to lower, increasing or higher risk drinkers = 3% population

8. Alcohol Dependence ICD-10 Compulsion – strong desire or sense of compulsion to take alcohol Loss of control – difficulties in controlling drinking in terms of onset, termination or levels of use Withdrawal – physiological state in response to cessation or reduction of use, or drinking to relieve or avoid withdrawal symptoms Tolerance – increased doses required to achieve effects originally produced by lower doses Pre-occupation with alcohol – progressive neglect of alternative pleasures or interests, or increased amount of time to obtain or take alcohol, or recover from its effects Persistent use – continued use despite evidence of harmful consequences

9. World’s first wine Ancient Persian fable A princess having lost favour with the King attempts to poison herself by eating a jar of “spoiled” grapes. She became intoxicated & giddy & fell asleep. When she woke up she found the stressors that made her life so intolerable dispersed. Her subsequent conduct changed so remarkably that she regained the King’s favour. He shared his daughter’s discovery with his court & decreed an increase production of “spoiled” grapes

10. The evidence… Jar one of six vessels found at Neolithic village site in Iran Remains of a 7,000 year old wine Chemical tests show evidence of grape & resin from a tree used as a preservative showing that wine was deliberately made & not just unintentional fermentation of grapes http://www.archaeology.org/9609/ newsbriefs/wine.htmlhttp://www.archaeology.org/9609/ newsbriefs/wine.html

11. Identification & Brief Advice IBA pathway –Initial Screening to identify whether an individual is drinking above lower risk levels –Full Identification to define level of risk –Brief Advice & Referral if necessary

12. Screening Tools 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 of get rid of a hangover? (Eye- opener)

13. AUDIT High sensitivity 92% & specificity 94% 10 questions Detects all types of alcohol misuse Scores >20 possible dependence Too time consuming, therefore shorter versions used as pre-screen have similar validity & reliability

14. AUDIT-C 3 questions from AUDIT Short Indicates whether an individual is potentially drinking at increasing or higher risk levels Does not detect alcohol dependence

15. AUDIT-PC For use in primary care 5 questions Identifies increasing or higher risk levels

16. Brief Advice Is the patient willing to change? Use Readiness Ruler On a scale of 1-10 “How important is it for you to change your drinking?” Useful framework is stages of change model

18. Elements of Brief Interventions For hazardous or harmful drinker willing to change Feedback – present screening results Responsibility – emphasis on personal responsibility for change Advice – to cut down or abstain Menu – options for changing drinking pattern, jointly with patient establishing goal(s) Empathic interviewing – active listening, without confrontation, exploring with patients reasons for change Self efficacy – encouragement

19. In practise… Some statement to prepare the patient for intervention Give patient leaflet List common effects of drinking Give feedback on other people Provide information – point out benefits of cutting down Establish a goal Explain units & give advice on limits Provide encouragement

20. Video For video link go to http://www.alcohollearningcentre.org.uk/Topics/Latest/ Resource/?cid=5059 http://www.alcohollearningcentre.org.uk/Topics/Latest/ Resource/?cid=5059

21. Detoxification Alcohol dependence Increasing or higher risk drinker who has not responded to previous brief intervention If the drinker wants to stop drinking refer to community alcohol team for support & treatment Involve family & friends Give general advice Drinkers should set a ‘stop drinking’ date Stress that medication does not stop urge but reduces withdrawal symptoms

22. Community Detoxification Usually uses a reducing regimen of chlordiazepoxide over a week long period Referral to CAT –For Derbyshire county this is 01773 829966 –For Derby City: Bradshaw Clinic, 1 Charnwood St, Derby 01332 221700 –Addaction Frequent follow-up by CAT worker Ensure patient is taking thiamine supplements 200mg daily for at least duration of detoxification

23. 54 yr old, male You have arranged follow-up as he is undergoing community detoxification As he walks into the consultation room you notice he is unsteady On questioning he appears confused He cannot remember the events the previous day What are you worried about?

24. Wernicke-Korsakov Syndrome Any sign of Wernicke-Korsakov’s patients should receive Pabrinex in a setting with appropriate resuscitation facilities Signs: confusion, ataxia (truncal), ophthalmoplegia, nystagmus, memory disturbance, hypothermia, hypotension, coma Should continue over several days ideally in an inpatient setting In the community patients at risk of Wernicke- Korsakov’s should be given intramuscular Pabrinex

25. Inpatient Detoxification Confusion or hallucinations History of previously complicated withdrawal Epilepsy or history of fits Malnourishment Severe vomiting or diarrhoea Is at risk of suicide Has severe dependence coupled with poor co- operation Failed detoxification at home Uncontrollable withdrawal symptoms Acute physical or psychiatric illness Multiple substance misuse Poor home environment unsupportive of abstinence

26. 26 yr old, female Decides to abstain from alcohol She normally drinks 3-4 glasses of wine/day Her flat mate calls the surgery asking for a home visit as she is worried about her She feels hot, sweaty, palpitations, doesn’t know where she is, seems to be drifting in & out of consciousness, claims she can see things that aren’t there like crawling insects What are you worried about?

27. Medications to prevent relapse Acamprosate –Enhances GABA transmission & inhibits glutamate –Reduces craving in postwithdrawal period –Should be prescribed for min. 12 months Disulfiram (Antabuse) –Deters patients from resuming drinking –Unpleasant reaction – blocks metabolism of alcohol –Can be dangerous –Minimum of 6 months

29. Follow-up & support groups Patient motivation Self-help & support groups –Alcoholics Anonymous www.alcoholics- anonymous.org.ukwww.alcoholics- anonymous.org.uk –www.al-anon.org.ukwww.al-anon.org.uk –Drink aware www.drinkaware.co.ukwww.drinkaware.co.uk –Alcohol concern www.alcoholconcern.org.ukwww.alcoholconcern.org.uk Encourage to contact GP if relapse occurs Patients need to know that if they relapse there are still support strategies in place

30. Happy St Patrick’s Day!

31. Resources Bolland, W. (2008) Alcohol and primary care. InnovAiT. 1 (2) 141-149 Patel, I. (2010) Alcohol and depression. InnvoAiT. 3 (3). 155-165 www.alcohollearningcentre.org.uk Clinical Knowledge Summaries. Alcohol – problem drinking. Accessed via www.cks.nhs.uk/alcohol_problem_drinking www.cks.nhs.uk/alcohol_problem_drinking Scottish Intercollegiate Guidelines Network (SIGN) The Management of Harmful Drinking and Alcohol Dependence in Primary Care (2003) Available from www.sign.ac.uk/sign74.pdf www.sign.ac.uk/sign74.pdf