Management of Problem Alcohol Drinking

1
Management of Problem Alcohol Drinking

• Arun Rai

2
Introduction

• In Scotland majority of people enjoy drinking
• People have different drinking behaviour at
  different times in their lives
• Alcohol problem can affect people of all ages
  from all backgrounds at anytime.
• Harmful drinking and alcohol dependence are
  common and cause huge morbidity, mortality and
  burden to the NHS

3
(No Transcript)
4
Sobering Statistics

• In Scotland 16-74 yrs 93 men and 87 women drink
• At any one time 250,000 people report symptoms of
  mild alcohol dependence and 16,000 report
  moderate/severe symptoms
• Deaths due to alcohol misuse gt 2 time between
  1990 and 1999 and continue to rise (1 vs 25)
• Alcohol dependent patients consult their GPs
  twice as frequently as others patients
• Estimated cost of alcohol problems in Scotland is
  1 billion, but real cost is thought to be much
  higher
• It attributes 10 AE attendance
• 3 of all acute hospital admissions had alcohol
  related diagnosis
• Acute hospital admission malefemale 21

5
Sobering Statistics Cont

• Average weekly consumption 16-64 yrs age (in
  units), male 20.1 (1995) 19.8 (1998) female
  6.3 (1995) 7.4 (1998)
• Male from most deprived areas are 7 times more
  likely to die alcohol related deaths than in
  least deprived areas.
• UK Government revenue from alcohol was 11.5
  billion in 1999/2000
• Drinks and Hospitality sector is Scotland's
  largest employer (200,000)

6
(No Transcript)
7
Definitions

• 1 Unit 8g ethanol ½ pint of 3.5 beer 25ml
  spirit.
• Small glass of wine (125 ml) average strength
  1.5 Unit
• Hazardous Drinking
• More than 5 Units per day for men
• More than 3 units per day for women
• More than 21 units per week for men
• More than 14 units per week for women
• Harmful Drinking (ICD-10) Pattern of drinking
  causing damage to physical or mental health
• Alcohol Dependence Alcohol use takes much
  higher priority than other things that previously
  had greater values. Central characteristics is
  desire (strong) to drink.

8
Detection and Assessment

• Clinical Presentation where role of alcohol
  should be considered
• Screening for alcohol dependence
• Biological Markers

9
Clinical Presentation

• Social
• Marital disharmony/domestic violence
• Neglect of children
• Criminal behaviour ie driving offences,
  shoplifting, peace breach
• Unsafe sex, financial difficulties
• Occupational
• Repeated absenteeism esp. around weekends
• Poor employment record
• Poor performance at work
• Mental
• Memory Problem
• Anxiety, Panic, depression
• DSH
• Alcohol hallucinosis

10
Clinical Presentation (Contd..)

• Physical
• Multiple presentation to AE with trauma/head
  injury
• GI symptoms
• Cardiac arrhythmias Paroxysmal AF/SVT
• High BP
• Stroke
• Cardiomyopathy
• Peripheral neuropathy, cerebellar ataxia
• Impotence libido problems
• Blood dyscrasias
• Seizures
• Cancers Mouth, pharynx, larynx, oesophagus,
  breast, colon
• Gout
• Skin Rosacea, psoriasis, bruising

11
Screening for Alcohol Dependence

• AUDIT (Alcohol Use Disorders Identification Test)
• Very sensitive but time consuming
• CAGE (tries to Cut back drinking, Annoyed at
  criticisms, Guilty about drinking, using alcohol
  as Eye-opener)
• Not very sensitive to detect hazardous drinking
• CAGE plus two (max daily and total weekly
  consumption)
• As sensitive as AUDIT
• FAST (Fast Alcohol Screening Test) abbreviated
  version of AUDIT but sensitive and practical
• PAT (Paddington Alcohol Test) 1 min test useful
  in AE

12
Biological Markers

• Elevated MCV
• Elevated GGT
• Elevated CDT (Carbohydrate deficient transferrin)
• Blood Alcohol Concentration
• Breath Alcohol
• Saliva Alcohol test

13
UK Drink Driving Limits

• Blood Alcohol 80mg per 100 ml of blood
• Breath Alcohol 35 micro gram per 100 ml breath
• Urine Alcohol 107mg per 100 ml urine

14
Brief Intervention

• Has a proven role in management of problem
  drinking
• Can be 5 45 min
• FRAMES
• Feed back about personal risk
• Responsibility for change
• Advice to cut down or stop
• Menu alternative options, setting target etc...
• Empathic interview
• Self efficacy
• Not effective for severely affected patients
• Effective when opportunistic encounter
• Effectiveness NNT 7 9

15
Detoxification

• Planned withdrawal of alcohol
• Community vs Hospital No difference in
  soberness six month later
• 75 may be detoxified safely in community
• Home detox saves cost
• Many patients prefer home detox
• Resources required for community detox
• Home detox has no extra clinical benefit than
  hospital detox

16
Indication for Hospital Detox

• Confusion
• Hallucinations
• History of complicated withdrawl
• History of seizure
• History of failed home detox
• Under nourished
• Severe vomiting or diarrhoea
• Suicide risk
• Severe dependence and unwillingness to be seen
  daily
• Multiple substance misuse
• Acute Physical or Psych Illness
• Home environment unsupportive of abstinence

17
Pharmacological Intervention

• Thiamine
• Vitamin B/Multi Vitamin
• Pabrinex
• Chlordiazepoxide
• Diazepam
• Disulfiram
• Acamprosate
• Naltrexone
• SSRIs

18
Sensible Drinking

• Weekly Limit male 21 units, female 14 units
• Daily upper limit male 4 units, female 3 units
• Should have 2 alcohol days per week
• Has small health benefit for CHD prevention in gt
  40 yr men and post menopausal women
• Probable Protective effect for gall stones

19
T.A.P.S

• Provided by Tayside PCT
• Funded by Tayside Health Board
• Access Direct by individual, Referral by GP/SW
• Individual counselling at outreach clinics
• Support and advice for relatives
• Telephone help line
• Residential Unit 6 or 12 day treatment
  programme at Sunnyside Royal Hospital, Montrose
• Support groups weekly meeting in Arbroath,
  Dundee, Perth
• Continuing to expand and improve services