Alcohol dependent Flashcards
What to ask?
- Current, past and family history of alcohol use
- How much? Low. Hazardous. Harmful
Male. <4. 5-6. >6
Female. <2. 3-4. >4
Screening questions: CAGE
C- Need to CUT down
A- Annoyed when criticised by other ppl about drinking habit
G-GUILTY about the drinking habit
E-Eye opener-using ETOH as eye opener
1 pos answer- indicates need for futher assessment
2 pos answer- sensitivity 85%
-specificity 90% for alcohol dependence and abuse
What is Alcohol dependence?
- Tolerance- able to drink more than other ppl before getting side effects
- Withdrawal symptoms occur when stop
- Substance taken more than what initially intended
- Persistent desire to cut down
- TIme spent obtaining, using and recovering from alcohol is higher than others
- Social, occupational and recreational tasks are sacrificed
- Use continues despite physical and psychological problems
Alcohol abuse
- Failure to fullfill work, school and social obligations
- Recurrent substance abuse use in physically hazardous situation.
- Recurrent legal problem related to substance use
- Continued use despite alcohol related social or interpersonal problems.
What can affect treatment of alcohol use?
- Physical, social and emotional problems
- Physical complications of ETOH use
- Blood abnormalities
Identify treatment goals
- Non dependent—–> Controlled drinking if harm not severe
- Dependent- organ damaged/ controlled drinking failed————————>Recommend abstinence ( 55% reach a stable pattern)
Treatment of Alcohol dependence/ abuse
- Brief intervention- designed to increase motivation
- Counselling
- Medications- to start after abstinent
i. Acamprosate
ii. Naltrexone
iii. Withdrawal
4.Organise referral to detox unit and adequate follow up
Brief intervention
Empathy expressed
Feedback of ETOH and related health issue
Advice to change habit
Menu of strategies offered
Acamprosate
GABA agonist , use for 1 year
Side effects: Diarrhoea
Naltrexone
miu /u opiate receptor antagonist
Side effects: Nausea, dizzy, depression and headache, hepatic enzymes abnormality
Withdrawal management in alcohol dependent/abuse
Hospitalisation for diazepam, monitoring of seizure/risk, encephalopathy, liver disease, pancreatitis, malnutrition with electrolyte abnormalities and infection.
How you would treat this patient alcohol dependence?
I would consider brief intervention such as assist with acute withdrawal, then counselling using the drug and alcohol services available to me. If patient demonstrate readiness to quit, I would then consider recommending medication once patient has a period of abstinent such as using Acamprosate and Naltrexone. I would consider referring patient to detox unit with adequate follow up therafter.
In your opinion, do you think this patient has alcohol dependence?
In my assessment, Mr. XX has been unable to fullfillhis work requirement by calling in sick regularly as well as using alcohol despite that he has recurrent severe abdominal pain and pancreatitis. He has also been caught drink driving on 1 occasion in the last 1 years and continued drinking despite that his wife showed extreme dislike for his continued drinking.
- Failure to fullfill work, school and social obligations.
- Recurretnuse despite physically hazardous situation
- Recurrent legal problem related with use
- Continued use despite social and interpersonal problem.
How do you manage this patient alcohol dependence?
5 A’s
( ASK)
First, I would ask his alcohol consumption level and consider him to be at high risk of dependency based on CAGE ( 2 or > positive response to CAGE)
(ASSESS)
-I would assess his willingness to quit ( pre-contemplative, contemplative stage, preparation, action and maintenance)
- I have identified the obstacle to be ABC– peer pressure, anxiety
- Assess the pattern of drinking habits
- Assess for complication of drinking habit- medical/ physical and psychosocial- drink driving, occupation impact and also relationship difficulty
(ADVICE)
I would explain the benefit of alcohol moderation/ cessation- liver derangement, relationship, financial benefit.
(ASSIST)
I would suggest these strategies aiming for quit date in 3 months, by non-pharmacologically involving family and friends ( internal /personal) for support, enlisting external support such as NEXT step,psychological intervention- counselling and CBT; pharmacologically- i Would recommend inpatient vs out patient detoxification and wll consider managing withdrawal state by using AWS with use of diazepam,Thiamine supplementation
Prevention of relapse- I would consider pharmacotherapy with 3 potential medication- disulfiram ( block Alcohol metabolism) , Naltrexone ( opioid/ mu receptor blockade) and Acamprosate ( prevents excitation of neurons from alcohol )
( ARRANGE FOLLOW UP)
I would link him with GP to follow up in 1 week to assess side effect and manage patient symptoms.
Acute complication af ALcohol dependence
- acute intoxication- supportive treatment
- Alcohol withdrawal syndrome ( 6-24 hours after alcohol use)
- Wernicke encephalopathy ( Ataxia, ophthalmoplegia, confusion)- after3 days
Treat with thiamine
-Korsakov
- severe antegrade and retrograde amnesia
Chronic complication
-Myopathy, parotid enlargement, dupuytren contracture
-PN
-Macrocytic anaemia
-Liver cirrhosis
-Bone marrow suppression
- Cerebellar degeneration
-Cognitive impairment
- Malnutrition
-Psycho-social issue- sick leave, relationship, criminal acts
SAFE drincking level- 2 std drink
I std drink 10 g of alcohol ( 100ml of wine, 300ml of full strength beer)
