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RCGP SMAH
10 minute approach to alcohol
Practice based learning session
Aims
Identify alcohol related problems and make a treatment plan in a primary care setting
Overview of the session
14.00
What does alcohol mean to you?
14.15
How to diagnose alcohol problems
14.45
Learning trios
15.30
Coffee Break
15.45
Medical Aspects
16.45
Finish and Evaluation
What does alcohol mean to you?
• Have you had any experiences with patients who drink?
• Do you drink?
• How does drinking affect you?
How to diagnose alcohol problems
Screening tools
Calculating alcohol units
Brief Intervention
…is a method of identifying alcohol consumption at a level sufficiently high to cause concern.
Alcohol Screening…
Screening tools in primary care
AUDIT alcohol use disorder identification test
FAST fast alcohol screening test
AUDIT-C AUDIT alcohol consumption questions
AUDIT-PC AUDIT primary care
M-SASQ modified single alcohol screening question
Coulton S, Drummond DC, James D, Godfrey C, Bland JM, Parrott S, Peters T: Opportunistic screening for alcohol use disorders in primary care: comparative study. British Medical Journal 2006 , 332:511-7.NICE public health guidance 24: Alcohol-use disorders: preventing harmful drinking, Evidence statement e5.1
AUDIT
• Developed by the WHO specifically for use in primary care, validated in more than 22 countries
• gold standard in screening tools• Sensitivity 92% and specificity 94% to identify
increased, higher risk and possible dependent drinking
Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption. Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M. Addiction. 1993 Jun;88(6):791-804.
ScoreDH
TerminologyNICE/WHO
Terminology
0 - 7 Lower Risk
8 - 15 Increasing RiskHazardous Drinking
16 - 19
Higher Risk Harmful Drinking
20 - 40
Possible Dependence
AUDIT scores
AUDIT Score
NICE/WHO Terminology
0 - 7 Lower Risk Within recommended limits
8 - 15 HazardousAbove recommended limits
no significant harm
16 - 19 HarmfulAbove recommended limits
AND significant harm
Clinical definitions
Typology (general population)
DoH 2005
Severely dependent drinkers (< 0.1%)
Moderately dependent drinkers (< 0.4%)
Harmful drinkers (4.1%)
Hazardous drinkers (16.3%)
Low-risk drinkers (67.1%)
Non-drinkers (12.0%)
Physical health risks
Condition Men Women
Hypertension
4x 2x
Stroke 2x 4x
CHD 1.7x 1.3x
Pancreatitis 3x 2x
Liver disease
13x 13x
Source: Safe. Sensible. Social: the next steps in the national alcohol strategy (HM Government, 2007)
What is Brief Intervention?
• can be anything from a short conversation to a number of sessions
Brief interventions help the patient to understand:
•What consequences likely to be
•What they can do about it
•What help is available
Who is Brief Intervention for?
AUDIT Definition Intervention
0 - 7 Lower risk Positive reinforcement
8 - 15 Hazardous Brief Intervention
16 - 19
Harmful Extended Brief Intervention
20 - 40 Possible dependence
Further Assessment
• Brief intervention is for hazardous and harmful drinking
• Usefulness is limited for dependent drinking
Brief Interventions
Brief Intervention Extended Brief Intervention
Increasing Risk Higher Risk
single consultation multiple consultations
Brief structured advise
Up to 45 minutes structured intervention
Goal setting Goal setting over time
Consider further examination
Physical examination and investigations
Limited follow-up Structured follow up
Structure of Brief Interventions
FRAMES
Feedback (personalised)
Responsibility (with patient)
Advice (clear, practical)
Menu (variety of options)
Empathy (warm, reflective)
Self-efficacy (boosts confidence)
Bien, T. H., Miller, W. R. and Tonigan, J. (1993) Brief interventions for alcohol problems: a review. Addiction 88, 315–336.
Does brief intervention work?
1 in 8
individuals drinking at hazardous or harmful levels act on their doctors advice and
moderate their drinking to low risk levels.
This compares to 1 in 20 individuals offered smoking advice (1 in 10 when nicotine
replacements are offered).
Alcohol: No Ordinary Commodity - Research and Public Policy (Babor et al 2003)
Does more intervention help more?
Brief Intervention:• is often as effective as more extensive
treatments• should not substitute for specialist treatment• Might serve as an initial treatment for
severely dependent
Bien, T, Miller, W.R. and Tonigan, J.S.Brief interventions for alcohol problems: A review. Addiction 88: 315-336, 1993.
Moyer, A., Finney, J., Swearingen, C. and Vergun, P. Brief interventions for alcohol problems: A meta-analytic review of controlled investigations in treatment-seeking and non-treatment seeking populations. Addiction 2002 Mar;97(3):279-92.
Calculating units of alcohol
Litres x ABV = Units
Examples: 1 Litre of 4% lager = 4 units
0.75 Litres of 12% wine = 9 units
Adults visiting GP
Requesting help with alcohol problem
New Registration Other health complaint
Full ScreenAUDIT
AUDIT Score8-15
Full Assessment
Referral to Specialist Services
ExtendedBrief Advice
AUDIT Score16-20
AUDIT Score20+
AUDIT Score 0-7
No action
PositiveResult
NegativeResult
FAST AUDIT - CInitial Screening Tools
Brief Advice
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© Department of Health 2008
Question time
Learning trios
• In groups of 3 you will take turns to be the GP/practitioner, patient and observer in role play – each person will have a go at being all three
• The patient and the GP will each play the character identified in the case given to them on the card
• The GP will deliver the AUDIT and undertake alcohol unit calculation
• The GP’s role is to respond and deliver a “brief intervention” to the patient if appropriate
• The Observer’s role is to note what helps and hinders the interactions between GP and Patient and then feedback to the GP and Patient in the five remaining minutes before swapping roles
• The exercise is completed when all members have had an opportunity to play GP, patient and observer
Brief intervention exercise
• Include an AUDIT assessment• Decide what level of intervention is
appropriate for your case• Conduct a brief intervention if appropriate
Learning trios
Feedback
How did you feel that went?
Any difficulties?
Any anticipated problems?
Learning trios
Tea break
15.45 Medical Aspects of alcohol
misuse
Next session
Medical Aspects
Investigations
Detoxification
Medication
Risks
Case Scenario
A 36 year old man attends your surgery on a Friday afternoon. Mildly intoxicated.
PC: He says that he is dependent on alcohol and will go into withdrawal soon as he ran out of money to buy alcohol. He requests an alcohol detoxification.
O/E: Overall well, no signs of malnourishment.
No signs of alcohol withdrawal
Case Scenario
A 46 year old woman attends your surgery.
PC Feeling unwell in the morning, vomiting at times
increasing memory problems
O/E Looks malnourished, without any specific findings. BP 155/90, pulse 90. Liver slightly enlarged.
As you have no idea what is going on, you request a blood test: FBC, U&E, LFTs, TFTs. All come back as normal apart from the LFTs, which are slightly raised (<2x normal).
Case scenario
A 25 year old man attends your surgery. He is drunk to a degree that he could not find your consultation room initially.
He requests a sick note as he is an alcoholic.
Investigations
Dependency makes physical harm caused by alcohol more likely
but
a substantial amount of harmful drinking patients will develop medical problems
Like in coronary heart disease, a low risk score does not guarantee safety.
Investigations
• Simple questionnaire-based screening tools are more effective to identify problematic drinking
• FBC (anaemia and raised MCV)
• LFT (consider GGT)
Abnormal blood tests – what now?
NICE recommends:
• Abnormal LFTs – exclude alternative causes of liver disease
• Refer to a specialist to confirm a clinical diagnosis of alcohol-related liver disease.
National Institute of Clinical Excellence: CG100 Alcohol-use disorders: physical complications. Published May 2010
GGT
• only elevated in 30% heavy drinkers • up to 50% of all raised GGT is due for other
reasons• less likely to be elevated in young people,
episodic drinkers, women• A possible tool in monitoring
Physical signs of alcohol misuse
• Peripheral neuropathy
• Signs of chronic liver disease
• Neurological symptoms
• Proximal myopathy
• Cardiomyopathy
• Enteropathy
• Signs of withdrawal
Why assess dependence?
… because it is dangerous not to!
• Sudden stop of drinking may result in developing serious and life threatening conditions such as withdrawal fits, delirium tremens and Wernicke’s encephalopathy.
• Non-dependent drinkers can usually cut down and reduce associated problems
• Dependent drinkers (by definition) find reducing more difficult.
• Dependent drinkers generally need assistance to stop drinking
Dependent vs harmful drinkers
• AUDIT > 16 requires further assessment• AUDIT score of >35 or >50U per day makes
dependence likely• Need for medically assisted withdrawal and
assessment of co-morbidity • SADQ
Quantifying dependency
AUDIT SADQSleep
durationEye
openerWith-
drawalUnits/day
Harmful 16+ <3 normal - - <15
Dependence
Mild 16+ <15 8+ hrs - + <15
Moderate 20+ 15-30 6-8 hrs + ++ 15-30
Severe 20+ 30+ 4-6 hrs ++ +++ 30+
• SADQ – establish severity of dependency• 20 item questionnaire• Score correlates with expected severity of withdrawal
ScoreSeverity of dependency
0-3 No dependency
4-19 Mild
20-30 Moderate
31+ Severe
Stockwell, T., Sitharan, T., McGrath, D.& Lang, . (1994). The measurement of alcohol dependence and impaired control in community samples. Addiction, 89, 167-174.
Who needs detoxification? Use SADQ!
A sobering thought…..
• Detoxification is but one event in a continuing process
• It is a technical step between preparation and aftercare
• As a stand alone treatment can do more harm than good
• Detoxification from opiates and alcohol are two very different events
• Detoxification from opiates is uncomfortable, but fairly safe, whilst detoxification from alcohol is potentially dangerous, and can be permanently disabling or fatal
Who doesn’t need detoxification?
• Generally <15 units/day (M) or 10 units/day (F)• No recent withdrawal symptoms• No drinking to prevent withdrawal• Occasional binges lasting <1 week• SADQ (Severity of Alcohol Dependence
Questionnaire) < 4
Where can detoxifications take place?
• General Hospital• Psychiatric Hospital• Non statutory rehab or detoxification unit• Community
Community detoxification shows similar outcomes to inpatient – 75% successful in community
Community setting preferred by most patients Accessibility and trust in practitioner is key advantage Cost advantage
Stockwell T, Bolt L, Milner I, Russell G, Bolderston H, Pugh P (1991). Home detoxification from alcohol; its safety and efficacy in comparison with inpatient care. Alcohol and Alcoholism;26(5-6):645-650.
Finney J, Hahn A, Moos R (1995). The effectiveness of inpatient and outpatient treatment for alcohol abuse: the need to focus on mediators and moderators of setting effect. Addiction;91(12):1773-1796
Alcohol Withdrawal Syndrome (AWS)
• Autonomic over-activity and hyperactivity• Anxiety and tremor• Nausea and vomiting• Sweating• Tachycardia• Hypertension• Pyrexia
Progression of AWS
Complications of AWS
• Withdrawal seizures
• Delirium Tremens
• Wernicke’s encephalopathy and alcohol confusional withdrawal syndromes
• Severe depression/suicide
• Cardiovascular catastrophe (CVA, MI)
Beware the older patient…
NICE guidelines on Detoxification
Acute alcohol withdrawal
For people in acute alcohol withdrawal with, or who are assessed to be at high risk of developing, alcohol withdrawal seizures or delirium tremens, offer admission to hospital for medically assisted alcohol withdrawal.
National Institute of Clinical Excellence: CG100 Alcohol-use disorders: physical complications (CG100). Published May 2010
Medication
Harm reduction
Thiamine, Vit B Costrong
Detoxification
Chlordiazepoxide, Diazepam, Carbamazepine
Relapse prevention or controlled reduction
Naltrexone Nalmefene
Disulfiram (Antabuse®) Acamprosate
Thiamine
Offer prophylactic oral thiamine to harmful or dependent drinkers:
• if they are malnourished or at risk of malnourishment or
• if they have decompensated liver disease or
• if they are in acute withdrawal or
• before and during a planned medically assisted alcohol withdrawal.
National Institute of Clinical Excellence: CG100 Alcohol-use disorders: physical complications. Published May 2010
Community Detoxification
Chlordiazepoxide
Day Total daily dose
1 120mg
2 100mg
3 80mg
4 60mg
5 40mg
6 20mg
7 10mg
Examples of a community detoxification regime:Total daily dose should be given in three to four divided doses
Diazepam
Day Total daily dose
1 40mg
2 35mg
3 30mg
4 20mg
5 15mg
6 10mg
7 5mg
Naltrexone
• Recommended by NICE, but not licensed for controlled reduction
• 50mg tablet once daily• Opioid antagonist• Can be used together with Acamprosate or on its own
Nalmefene
Similar mechanism to Naltrexone
Licensed in the UK to support controlled reduction
PRN up to once daily
Acamprosate (Campral®)
• Well tolerated
• reduces craving after a detoxification and might help
with cutting down alcohol intake
• 333mg two tablets tds (reduced if < 60kg)
• CI: renal failure, decompensated cirrhosis
• patients should engaged in aftercare• Varies in effectiveness between patients
Disulfiram (Antabuse®)
• Evidence for efficacy only if supervised• Numerous contraindications • Severe aversive reaction after any alcohol:
flushing, palpitations, hypotension, vomiting, headache
• Should be initiated in consultation with specialist service
Case Scenario - review
A 36 year old man attends your surgery on a Friday afternoon. Mildly intoxicated.
PC: He says that he is dependent on alcohol and will go into withdrawal soon as he ran out of money to buy alcohol. He requests an alcohol detoxification.
O/E: Overall well, no signs of malnourishment.
No signs of alcohol withdrawal
Would you do anything different now?
Case Scenario
Would you do anything different now?
A 46 year old woman attends your surgery.
PC Feeling unwell in the morning, vomiting at times
increasing memory problems
O/E Looks malnourished, without any specific findings. BP 155/90, pulse 90. Liver slightly enlarged.
As you have no idea what is going on, you request a blood test: FBC, U&E, LFTs, TFTs. All come back as normal apart from the LFTs, which are slightly raised (<2x normal).
Case scenario
Would you do anything different now?
A 25 year old man attends your surgery. He is drunk to a degree that he could not find your consultation room initially.
He requests a sick note as he is an alcoholic.
Question time
Competencies
Understanding, awareness and knowledge
Categories of problem drinking
Screening tools,
calculate units of alcohol
Awareness of alcohol related health problems
Skill
Use AUDIT questionnaire
Deliver brief interventions
Where can I learn more?
RCGP Alcohol Certificate
Alcohol Learning Centre
Summary and feedback
Please leave feedback forms!
You can email any suggestions to:
RCGP SMAH
You’ve done it!
Finish
