Alcohol

Question 1

Alcohol: PRICMCP?

Answer 1

P: how long, quantity (g/d), type of alcohol, pattern, drink alone vs. partner

R: bio (FH, other subs), psycho (MH), social (drinking partner, isolation, poverty)

I: CAGE

C: Heart failure, Cirrhosis/ALD, Neuro (W/Korsakoff’s, cerebellar, PN), Alcohol withdrawal (hx of seizures?), Social problems (jobs, family)

M: previous attempt to quit, why failed. Any drug tx previously?

C & P: willing to give a go in quitting?

Question 2

What are the risk factors for Alcoholism?

Answer 2

Biopsychosocial.

Bio: FH, other substance abuse including smoking

Psycho: hx of mental health illness

Social: isolation, drinking partners, poverty

Question 3

CAGE? How would you use it to assess the dependency?

Answer 3

Have you thought of Cutting down

Do you feel Annoyed when others criticize your drinking

Have you felt Guilty about your habit

Do you need an Eye-opener in the morning to settle your nerves

Two positive responses are about 80% specific and sensitive for alcohol abuse

Question 4

What is the National Health and MRC guidelines cut-off for drinking limit?

Answer 4

No more than 2 STD

No more than 4 STD in any day

Question 5

Significant dependence associated with a withdrawal syndrome on cessation is more likely in those whose regular consumption is greater than how many standard drinks/d?

Answer 5

More than 8

Question 6

What are the complications of chronic alcohol abuse?

Answer 6

Dilated cardiomyopathy

ALD & Cirrhosis

Neuro: cerebellar, W/K, PN

Haem: BM suppression

Psych: other substance abuse, anxiety, depression

Question 7

FLAGS?

Answer 7

Feedback - provide feedback on the impacts

Listen to their concerns

Advice: give advice on the benefits of quitting

Goals

Strategies

Question 8

How would you Mx Detox/Withdrawal?

Answer 8

Inpatient if high-risk of seizures or DT, otherwise outpatient

BDZ based on AWS: regular diazepam or oxazepam if there is liver dysfunction​​

eTG 2016 –> diazepam 20mg q2h max dose 60mg daily for withdrawal symptoms

Treat likely vitamin B1 deficiency:

Thiamine 300mg TDS IV/IM for 5 - 7 days then 300mg daily thereafter

Question 9

What are the 2 PBS approved options for pharmacologic in ETOH abuse?

Answer 9

Acamprosate

Naltrexone

Disulfiram (Ant-abuse), Baclofen and Topiramate are not.

Question 10

Acamprosate vs. Naltrexone differences that influence your choice? (2 pros & cons each, when compared with each other)

Answer 10

Acamprosate (synthetic GABA analogue)

Pros: no interaction with opioids, less side effects c/w naltrexone

Cons: larger pill burden, can’t use in pregnancy

Naltrexone (mu opioid receptor antagonist)

Pros: less pill burden (OD), better effect

Cons: contraindicated in liver failure - must be monitored. More side effects (headache, nausea, dysphoria)

Question 11

In a long case discussion, what are the 4 key components of managing alcohol abuse you should stem discussion based on?

Answer 11

1. Harm reduction (thiamine + physical safety - e.g. transport from pub)
2. Brief interventions (FLAGS)
3. Detox/withdrawal management
4. Relapse prevention

Question 12

What is your approach to managing this patient’s chronic alcoholism?

Answer 12

This is a difficult management issue that needs continued support and MDT approach

Goals: cessation/moderation of alcohol, prevent complications of chronic alcoholism

Confirm dx: collaterals, GGT, AST>ALT, Macrocytic anaemia

A: identify & treat coexisting disorders e.g. substance abuse, depression

Management

• Harm-reduction: Thiamine 100mg OD, ensure physical safety (e.g. using transport from the pub to home)
• Provide brief intervention: FLAGS (strategies will include Detox)
• Detox/withdrawal management
  
  • Inpatient (risk of DT/Seizures) vs. outpatient
  • Regular BDZ + PRN as per AWS
  • Thiamine
• Relapse prevention
  
  • Non-pharm: AA, counselling, CBT, consider residential rehabilitation
  • Pharm: Acamprosate & Naltrexone are PBS approved. Will educate on side effects if on Naltrexone (headache, nausea, dysphoria) - transient.

Involve: GP, family for continued support and close monitoring

Screen for complications: assess & investigate for HF, CLD, neuro, psych…etc.

Question 13

What are the components of CIWA (Clinical Institute Witdrawal Assessment) for alcohol? / or AWS (6)

Answer 13

1. Agitation
2. Tremor
3. Sweats
4. Anxiety
5. Nausea + Vomiting
6. Hallucinations: Visual/Tactile/Auditory
7. Fever

Question 14

Severity of withdrawal based on AWS?

Answer 14

<5 mild

5-14 moderate

≥15 severe

Question 15

Give example of regime that you’d use in managing Alcohol withdrawal (detox) in outpatient setting? or AWS <5 (MILD)

Answer 15

Day 1: diazepam 10mg QID

Day 2: diazepam 10mg TDS

Day 3: diazepam 5mg TDS

Day 4: diazepam 5mg BD

Day 5-6: 2.5mg BD then stop

Adjust based on AWS.

Question 16

How would you manage DT?

Answer 16

1. 20mg diazepam hourly upto 80mg total/24 hours
2. If too drowsy to take orals, ICU for ?intubation +

IV midazolam (5mg bolus then infusion at 2mg/h) - ICU

3. Alternative is 2mg IM lorazepam
4. Thiamine
5. If patient still not settled, consider olanzapine 10mg sublingual wafer
6. Involve D/A

Question 17

Mx of moderate withdrawal? what AWS score would that be?

Answer 17

AWS 5-14.

1. Hourly obs
2. Stat 10-20mg diazepam, then repeat 10-20mg 2 hourly until patient achieves good symptom control (total 80mg)
3. If not settling after 80m, give olanzapine 5-10mg