Alcohol misuse

Question 1

What is the difference between intoxication, harmful alcohol use and alcohol dependency

Answer 1

Intoxication = dose-dependent, transient state following use

Harmful = pattern of use that is likely to cause physical or psychological damage, non-dependent and continues despite established harm (social, mental, etc.). evident over a period of at least 12 months if substance use is episodic or at least 1 month if use is continuous

Dependence = need to use a substance to feel or function normally after a period of regular use (≥3 of 6 features of dependency)

Question 2

How are units of alcohol calculated

Answer 2

Units = % ABV (alcohol by volume) x Volume (Litres)

Question 3

What is the UK maximum for alcohol consumption and what is the threshold for hazardous and harmful drinking

Answer 3

14 units a week
Hazardous = 15-35
Harmful = >35

Question 4

Define binge drinking

Answer 4

> 8 units for men
6 units for women

Question 5

What are the symptoms of low levels of alcohol intake

Answer 5

Relaxing lowers inhibitions, makes people feel sociable and cheerful

Question 6

What are the symptoms of high levels of alcohol intake

Answer 6

Slurred speech
Poor coordination
Exaggerated emotions e.g. hilarity, tearfulness, misery, irritability
Disinhibition
Impulsivity
Poor judgement
Blackouts with amnesia for the drinking period

Question 7

What are the symptoms of severe levels of alcohol intake (alcohol poisoning)

Answer 7

Vomiting
Ataxia
Respiratory depression
Confusion
Coma
Death

Question 8

What is the 12 month and lifetime prevalence of alcohol use disorder

Answer 8

12 month: 1.3%
Lifetime: 5.4%

Question 9

What are the features of dependence

Answer 9

A strong desire or sense of compulsion to use
Difficulty in controlling use.
A physiological withdrawal state when use has ceased or been reduced.
Evidence of tolerance.
Progressive neglect of alternative pleasures and interests.
Persistence with use despite clear evidence of overtly harmful consequences.

Question 10

Define alcohol withdrawal

Answer 10

Withdrawal from alcohol in patients who are alcohol-dependent and have stopped or reduced their alcohol intake within hours or days of presentation

Question 11

What is the pathophysiology of alcohol withdrawal

Answer 11

Chronic alcohol use results in up-regulation of post-synaptic NMDA receptors and down-regulation of post-synaptic GABA receptors. A sudden decrease in blood ethanol concentration results in an imbalance between stimulatory NMDA and inhibitory GABA systems in the CNS
Abrupt alcohol cessation leads to overactivation of the excitatory NMDA system relative to the GABA system
→ Overactivity of the sympathetic nervous system

Question 12

What are the symptoms of withdrawal 6 hours post-drink

Answer 12

Anxiety/agitation
Palpitations
GI upset: nausea, pain
Sweating and tremor
Headache
Insomnia

Question 13

What are the symptoms of withdrawal 12 hours post-drink

Answer 13

Hallucinations: visual/tactile (usually insects on the skin)
Restlessness
Normal mental status

Question 14

What are the symptoms of withdrawal 36-46 hours post-drink

Answer 14

Confusion, agitation
Seizures: short, generalised, tonic-clonic

Question 15

What are the symptoms of withdrawal 48-72 hours hours post-drink

Answer 15

Delirium tremens:
- Profound confusion/delirium
- Visual, auditory and tactile hallucinations, characteristically frightening
- Lilliputian hallucinations (seeing little people) are characteristic.
- Insects on the skin
- Tactile: itch, burn, insects crawling
- Pins and needles, burning and numbness
- Coarse tremor
- Fever, tachycardia

Question 16

What are the signs of alcohol use disorder on examination

Answer 16

Obs: Hyper/hypotension, tachycardia
General: obs

Abdominal:
Palmar erythema
Clubbing
Bruising
Dupuytren’s contracture
Spider naevi
Gynaecomastia
Caput medusa
Hepatomegaly
Ascites

Question 17

What assessment tools can be used to screen for alcohol-use disorder

Answer 17

Fast alcohol screening test (FAST) → score of ≥ 3 is positive and would require further screening i.e. AUDIT
Alcohol Use Disorders Identification Test -
- Consumption (AUDIT-C): >5 = positive
- AUDIT: full version, takes much longer, harmful use >16, possible dependence >20
Paddington alcohol test 2011 (PAT)

SADQ (Severity of Alcohol Dependence Questionnaire)- use if scored > 15 on AUDIT
CIWA-Ar ( Clinical Institute Withdrawal Assessment of Alcohol)
GMAWS ( Glasgow Modified Alcohol Withdrawal)

Question 18

What investigations should be done for alcohol use disorder

Answer 18

Bedside: ECG (investigate any tachycardia, urine toxicology)
Bloods:
- VBG (hypochloraemic metabolic acidosis with high anion gap)
- glucose (hypoglycaemia)
- FBC (Macrocytic anaemia)
- U&Es (hypoMg+,K+,PO4)
- LFTs (elevated transaminases and GGT, AST/ALT ratio >2)
- Bone profile: hypoCa2+, hypovit D
- Coagulation screen: prolonged INR/PT due to CLD
- Amylase: exclude acute pancreatitis

Others:
suspected head injury, seizure, altered cognition → CT head

Question 19

What are the features of severe alcohol withdrawal

Answer 19

A high or worsening CIWA-Ar score
Failure to improve after two doses of benzodiazepines
Alcohol withdrawal delirium
Alcohol withdrawal seizure
Deranged temperature or deranged BP or deranged blood glucose, alongside any feature or alcohol withdrawal

Question 20

What are the complications of alcohol use disorder

Answer 20

Liver disease: Fatty liver → alcoholic hepatitis → cirrhosis
GI: pancreatitis, oesophageal varices, mallory-Weiss tear, gastritis, peptic ulceration
Neurological: increased cerebrovascular disease, peripheral neuropathy, myopathy, seizures, dementia, Wernicke-Korsakoff syndrome, cerebellar degeneration
Cancer: Mouth, pharynx, larynx, oesophageal, breast, bowel, liver, pancreas
Cardiovascular: ischaemic heart disease, HTN, cardiomyopathy
Head injury and accidents
Foetal alcohol syndrome
Depression, anxiety, self-harm, suicide
Cognitive impairment
Alcoholic hallucinosis: Auditory hallucinations during or after heavy drinking. oFten persecutory or derogatory
Morbid jealous: overvalued delusion of a partner’s infidelity
Social impairment: unemployment, poor work attendance, domestic violence, sexual exploitation, divorce, criminal acts

Question 21

What is the prognosis for alcohol misuse

Answer 21

withdrawal symptoms are worst within the first 48 hours and take 3-7 days after the last drink to completely disappear
Delirium tremens-related mortality is <1% if early and treated, but fatal in 15-20% of patients if untreated
50% of patients remain abstinent from alcohol for a year

Question 22

What is the management for acute alcohol withdrawal

Answer 22

Calculate CIWA-r score
1. Supportive care + treatment of any acute medical illness
a. Place in quiet room
b. Correct metabolic abnormalities, IV fluids if dehydrated
c. Electrolyte imbalance treatment
2. Thiamine - Pabrinex IV
3. Benzodiazepine (i.e. chlordiazepoxide), carbamazepine, clomethiazole
4. Consider glucose if hypoglycaemia
5. Airway management if required

Question 23

What is the management for delirium tremens

Answer 23

1st Line: PO Lorazepam
Second line: If symptoms persist, offer IV lorazepam or haloperidol
Alternative: chlordiazepoxide

+ IV Thiamine

Question 24

What is the management for alcohol withdrawal seizures

Answer 24

Consider fast-acting benzodiazepine (e.g. Lorazepam) to reduce the likelihood of future seizures
Offer advice on local support services

Question 25

What are the risk factors for Wernicke’s encephalopathy

Answer 25

Malnourished or at risk of malnourishment
Decompensated liver disease
Acute withdrawal
Before and during a planned medically assisted alcohol withdrawal
Attend A&E
Admitted to hospital with an acute illness or injury

Question 26

What is the management for wernicke’s encephalopathy

Answer 26

Parenteral (IV/IM) thiamine for at least 5 days
Follow with PO thiamine

Long-term
Supported independent living for those with mild cognitive impairment
Supported 24-hour care for those with moderate-severe cognitive impairment

Question 27

What is the management following successful alcohol withdrawal

Answer 27

Bio
First line: acamprosate or naltrexone for 6 months
Second line: disulfiram

Psycho
Individualised psychological intervention
- Motivational interview
- CBT
- Problem solving therapies
- Intensive structure community based intervention, group therapy
- Refer to specialist alcohol services

Social
Residential rehabilitation services for homeless patients (3 months max)
Refer to: alcoholic anonymous, SMART recovery, change, grow, live (CGL)
Care coordination
Case management
Offer carer’s assessment, guided self-help for families, support groups

Question 28

What is the MOA for alcohol withdrawal medication

Answer 28

Acamprosate: anticraving drug
Disulfiram (antabuse): discourages drinking by inhibiting acetaldehyde dehydrogenase → acetaldehyde accumulation → flushing, throbbing headache, nausea & vomiting
Naltrexone: opiate antagonist that leads to reduced dopaminergic activity and decreases pleasurable effects of alcohol

Question 29

What is the management for alcohol dependence that presents to primary care

Answer 29

Refer to specialist alcohol services for planned withdrawal OR alcohol detoxification programme
± prophylactic PO thiamine

Question 30

When is inpatient assisted withdrawal indicated

Answer 30

> 30 units/ day
30 scored on SADQ
History of epilepsy, withdrawal-related seizures or delirium tremens
Need concurrent withdrawal from alcohol and benzodiazepines
Drink 15-30 units/ day and have:
- Significant psychiatric or physical comorbidities
- Significant learning disability or cognitive impairment
Consider lower threshold in vulnerable groups (e.g. homeless, older people)
Children (10-17 years)- they should also receive family therapy for 3 months

Question 31

What is the CAGE questionnaire

Answer 31

Have you ever felt you needed to Cut down on your drinking?
Have people Annoyed you by criticising your drinking?
Have you ever felt Guilty about drinking?
Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover?

Score of ≥ 2 suggests excessive drinking