2. 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.

3. 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

4. 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

5. 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

6. Copyright restrictions may apply. bolland, W. InnovAiT 2008 1:141-149; doi:10.1093/innovait/inn006 Effects of high-risk drinking

7. 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:

8. 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

9. 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)?

10. 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!

11. 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.

12. 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

13. 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.

14. 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, non- judgemental fashion.  Self-efficacy—An attempt to increase the patient's confidence in being able to change behaviour.

15. 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

16. 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

17. Alcohol Related Emergencies  Three main ones you need to know: Fits Delirium Tremens Wernicke’s/Korsakoff’s

18. 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.

19. 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

20. 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

21. Thanks for Listening!