‘ R e v o l v i n g d o o r p a t i e n t s ’ — t h e a f t e r c a r e a n d monitoring of patients with alcohol dependence syndrome in a primary care setting in Salford

1,059,210 admissions(2013-14)

PoisoningMental and behavioral disordersAlcoholic polyneuropathyAlcoholic myopathyAlcoholic liver diseaseGastritisCardiomyopathy

Acute and chronic pancreatitisAccidents, injuryChronic liver diseaseDiabetes mellitusEpilepsy and status epilepticusFallsPeptic ulcerationOesophageals varicesHeart faiure

F u l l y attributable

P a r t i a l l y attributable

Alcohol Dependence Syndrome (ICD-10)> 3 of the following criteria:

✤ Strong desire or sense of compulsion to take the substance;

✤ Difficulties in controlling substance-taking behaviours;

✤ Physiological withdrawal state when substance use has ceased or has been reduced, or taking the substance with the intention of relieving or avoiding withdrawal symptoms;

✤ Evidence of tolerance;

✤ Progressive neglect of alternative pleasures or interests;

✤ Persisting with substance use despite clear evidence of overly harmful consequences.

> 15 units / day

Treatment Goal: Abstinence

Prevalence — 5.9%

94 patientsAlcohol dependence syndrome

Female33,33 %

Male66,67 %

Unemployment — of working age,87% affected by alcohol

Psychiatric co-morbidity 63% of all patients

78% of whom, depressed43%, anxious

50% of all patientsattended A&E for alcohol-related reasons

74%

Alcohol Use Disorders Identification Test(AUDIT)

Comprehensive screening tool (1995, WHO)

✤ Frequency

✤ Impaired control

✤ Morning drinking

✤ Injury

✤ Blackouts

✤ Guilt

8.5% — AUDIT > 20, documented at least once 5% — AUDIT 16-20, documented at least once

99% — units consumed were recorded as well as other metrics, e.g. ‘Ex-drinker’, ‘Light drinker’, ‘Moderate drinker’, ‘Harmful drinker’

79% offered ‘structured brief in te rven t ion ’ ( i .e . hea l th education)

8 1 % h a d h a d r o u t i n e biochemical tests

Useful for screening for:

Macrocytic anaemia Deranged LFTs↑ GGT

PRECARE

16%

Self-help groups

51%T h i a m i n e (Vitamin B1)

52%

Psychological inpute.g. primary care mental health, psychiatric referral

Documented referrals to

% of all patients who accessed at least once

AFTERCARE

80%

Psychological inputfor those with pre-existing co-morbid psychiatric disorders

100% prescriptions maintained by G.P.

Acamprosate ( c a m p r a l ) , d i s u l f i r a m ( A n t a b u s e ) , thiamine

83% of all patients who received a medically assisted withdrawal, or other support, from CAT, relapsed.

This was revealed through A&E attendances for alcohol-related reasons in 41% of these patients.

Final review of records — at the end of the audit:

40 out of the 94 patients had achieved abstinence or self-moderation when last screened

✤ Systematically screen all patients using the AUDIT

✤ Use abbreviated AUDIT tools (FAST, AUDIT-C), in consultations, where relevant

✤ Signpost patients to assisted withdrawal services and open-access group therapies

✤ Continue following up prescriptions of relapse prevention medications initiated by CAT

✤ Ensure all these are reviewed on 6-monthly basis by biochemical assessment

✤ Continue to refer those with persistent psychological symptoms for psychological and psychiatric support

✤ Follow up patients after assisted withdrawal using low-intensity measures (e.g. telephone calls), for at least 3 years afterwards