Alcohol abuse

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Alcohol abuse

• Dr Allister J Grant
• Consultant Hepatologist
• University Hospitals Leicester NHS Trust

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Definitions

• Weekly safe limits
• 21 units 14 units
• Harmful Drinking
• 22-50 units 15-35 units
• Hazardous Drinking (very heavy)
• gt50 units gt35 units
• Binge drinker
• gt10 units gt7 units in one session

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The Burden of Alcohol

• 9 million adults in the UK who are drinking over
  the recommended daily limits
• people aged 16-24 are the heaviest drinkers
• The Royal Liverpool University Hospital, 12 of
  AE attendances were shown to be directly related
  to alcohol
• In inner city AE departments approximately 75
  of patients attending after midnight are drunk
• 20 of patients admitted to hospital for
  illnesses unrelated to alcohol, are drinking at
  hazardous levels

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• In 2000
• 32 of 16-19 year old women had a hazardous
  drinking problem
• 61 of 20-24 year old men had a hazardous
  drinking problem

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Taking an Alcohol History

• 1 unit Xg EtOH half pint normal
  beer/lager small glass of wine
• pub measure of spirits

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Detection of patients with excessive consumption

• Include in general lifestyle review (including
  smoking, exercise, diet etc)
• Non-judgemental approach
• Quantity / frequency assessment
• Other questionnaires, eg
• CAGE
• AUDIT
• MAST

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Harmful effects of alcohol
ALCOHOL
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Neurological Effects of Alcohol

• Acute intoxication
• Blackouts
• Withdrawal- hallucinations, tremor, fits
• Persistent brain damage - WE/ Korsakoffs
  Psychosis, Cerebellar degeneration, dementia,
  Marchiafava-Bignami Syndrome
• Cerebrovascular disease- strokes, SAH
• Head Injury- SDH, EDH
• Nerve and muscle damage- Peripheral Neuropathy,
  myopathy, rhabdomyolysis

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Alcohol Withdrawal

• GABA ,Glutamate ,DA ,Adrenalin
• Occurs in 40- not related to amount
• Hallucinations - 25 of heavy drinkers
• within 24hrs of last drink
• May be leucid unlike the DTs

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Alcohol Withdrawal

• DTs occur in 5
• 2-5 days post cessation
• Auditory/visual hallucinations
• Reduced consciousness/ confusion
• Delusions
• Tremor
• HRgt100
• Agitation
• Fever
• Autonomic over activity

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Symptoms of DTs
Autonomic overactivity
NO YES
Chlordiazepoxide 50mg/2h Or Diazepam 10mg iv
every 30-60mins Or Lorazepam 2mg iv followed by
1mg 4-6 hourly With Pabrinex iv 2 amp pairs tds
Withdrawal symptoms
MILD MOD/SEV
Admit and continue treatment
Oral chlordiazepoxide With Pabrinex iv 1 amp
pair/d
YES
Risk factors for progression gt15u/d, Hx of
seizures/DT Malnourishment, high anxiety,?Glc,?K,
No treatment necessary
NO
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Oral Chlordiazepoxide Regime
Breakthrough doses Appropriate fluid and
electrolyte management, K, Glc, Mg,
PO4 Nursing Care
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Wernickes Encephalopathy

• 12.5 of alcohol misusers
• Fatal in 17
• Permanent damage in 85 if inappropriately
  managed survivors
• Acute/ subacute Mental Changes 82
• Ataxia 23
• Eye signs 29

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Mechanism of cell death in WE
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Management of Wernickes Encephalopathy
Alcohol misuser with one of Acute
confusion Reduced conscious level Memory
disturbance Ataxia/unsteadiness Opthalmoplegia Nys
tagmus Unexplained hypotension/hypothermia
YES
NO
WE
Risk factors Intercurrent illness DTs/seizures W
t loss Malnutrition DV gt20units/d Peripheral
neuropathy
Pabrinex iv 2 ampoule pairs tds For 2-3 days
then 1 ampoule pair daily For 3-5 days
YES
Pabrinex iv 1 ampoule pair daily For 3-5 days
Admit and treat
NO
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Hepatic Complications of Alcohol

• Fatty Liver
• ASH
• Alcoholic Hepatitis
• Cirrhosis
• HCC

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Hepatic Pathology
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GI Complications

• Reflux, vomiting, carcinoma of mouth, oesophagus,
  large bowel
• Gastritis, impaired ulcer healing
• Small bowel diarrhoea and malabsorption
• Pancreas- Acute and chronic pancreatitis, Ca
• Malnutrition, weight loss

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Cardio-Respiratory

• Cardiomyopathy
• Arrhythmias
• Hypertension
• Cardiac Beriberi
• Rib
• Pneumonia

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Metabolic Complications

• Pseudo-Cushings Syndrome
• Hypoglycaemia
• Obesity
• Hypogonadism
• Hyperuricaemia
• Hyperlipidaemia

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Psycho-Social Forensic Complications

• Impaired work/loss of job
• Accidents
• Marriage breakdown
• Depression

• Drink driving convictions
• Drunk and disorderly
• Domestic violence

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Drinking Cessation

• Detoxification
• Specialist Alcohol Rehabilitation
• Brief Interventions
• Pharmacotherapy

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Brief Interventions

• Aimed at hazardous drinkers
• Short duration and user friendly
• Generalist workers in non-specialised settings
• Consists 1) assessment of intake
• 2) info on harmful/hazardous drinking
• 3) advice, booklets and local services

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Effectiveness of brief intervention systematic
review 7 trials

• Some 20 - 30 of excessive drinkers will revert
  to sensible level of drinking for at least 1
  year.
• In general practice, 5 - 10 minutes intervention
  with follow-up leads to around 25 - 35
  reduction in alcohol consumption.

Freemantle N, Gill P, Godfrey C. Effective Health
1993
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