Alcohol Dependence

Question 1

How to calculate units in a drink

Answer 1

Capacity of drink
How many
% of alcohol

Ml x alcohol%

Question 2

Alcohol related diagnoses

Answer 2

Harmful use of alcohol - episode or recurrent
-use of substance with physical or mental harm

Alcohol dependence - 2 of 3

• loss of control over use
• alcohol use becomes high priority
• physiological signs - tolerance, withdrawal, drinking to prevent withdrawal

TOLERANCE IS RISK TO PROGRESSING TO WITHDRAWAL
WITHDRAWAL IS A LATE SIGN

Question 3

How to use AUDIT

Answer 3

0-7 - low risk = no action
8-15 - increased risk = brief advice
16-20 - high risk = consider 2ndary care/alcohol care team referral
20+ - dependence = 2ndary care/alcohol care referral
-assess for physiological dependence

Question 4

How to give brief advice for alcohol use

Answer 4

Feedback - discuss risks associated with use and listen to response
Responsibility - up to the patient to choose
Advice - ways of changing
Menu - provide patient with options
Empathy - warmth, respect and understanding
Self efficacy - empowerment

Question 5

Specific withdrawal symptoms you must ask about

Answer 5

Similar to bad hangover

• sweating
• headache
• anxiety
• nausea

Shaking - most people remember when they started shaking

Withdrawal

• seizures
• delirium

Question 6

Pathophysiology of alcohol withdrawal

Answer 6

Acute alcohol =>

• increased GABA binding => more Cl flow into neuron => relax
• also inhibits NMDA receptor

Chronic alcohol =>

• decreased GABA activity => sudden lack of GABA activity
• increased SNS activity
• increased D activity => hallucinations

Question 7

Red flags for complicated withdrawal

Answer 7

Presents with/past seizure
Presents with/past DT
Delayed presentation with unmedicated withdrawal
30units+ a day
Multiple withdrawal episodes

Question 8

Alcohol withdrawal timeline

Answer 8

Seizure - 1st 24hours

DT - 48hrs+

Question 9

How to plan for medically assisted withdrawal

Answer 9

Build a good rapport with your patient
-come up with strategies to cope with withdrawal symptoms and dependence

Location of withdrawal depends on

Question 10

Management of alcohol withdrawal

Answer 10

Diazepam or chlordiazepoxide

Use oxazepam or lorazepam in advanced liver disease due to no build up of metabolites

Question 11

Who needs short acting BZ

Answer 11

Diagnosis, stigmata of cirrhosis - vv high GGT

Limited capacity to synthesise/metabolise - bilirubin, albumin, INR

Portal hypertension - low platelets

Hepatic encephalopathy - delayed response, slurring, flap

Question 12

Management

Answer 12

Symptom triggered

• use CIWA withdrawal scale 2-4hrs
• Chlordiazepoxide

Fixed dose
-prespecified doses of BZ based on alcohol history or SAD!

Question 13

Alcohol withdrawal seizures

Answer 13

From BS

Manage with BZ

Question 14

Diagnosis of delirium tremens

Answer 14

Hx of dependence
Past presentation consistent with withdrawal
Agitated delirium
Mild form - perceptual disturbances to frank hallucainations and delusions

Slow progression

• light sensitivity
• seeing small patterns => insects, animals, people
• auditory hallucinations

Question 15

Management of delirium tremens

Answer 15

A&E team needed, ITU contact
Side room, 1 on 1, family involvement
-frequent reorientation

High dose BZ + Pabrinex

Question 16

Complications of DT

Answer 16

Aspiration pnenumonia => sepsis
Undiagnosed cirrhosis - hepatic encephalopathy
WKS - parenteral thiamine
-risk = 3 pairs
-any signs = 2 pairs 3x a day for 5 days
-treat any hypoMg
-you only have 1 month supply of thiamine
Cerebral pontine myelinosis =>

Question 17

WKS triad

Answer 17

Opthalmoplegia
Ataxia
COnfusion

Hx of malnutrition, pins and needkes
COnfusion, coma, delirium

Question 18

Aftercare

Answer 18

Explore what has helped before, current motivations

AA in reach/online

Links with community alcohol team