Dependance: Alcohol Flashcards
Define
Definitions
Harmful (misuse)= non-dependent and continues despite established harm (social, mental, etc.)
Dependence = harmful use + dependence syndrome (≥3 of 6 features of dependency)
Levels of alcohol consumption:
- Low risk (less than 14U is low risk): ≤14 U / week (men AND women)
- Hazardous drinking (intake increases risk of alcohol related harm): 15-35 U / week
- Harmful drinking (synonymous with alcohol misuse): >35 U / week (i.e. >6 U/day)
Aetiology
Multifactorial
- Determined by biological, psychological and sociocultural factors
Genetics
- 25-50% of predisposition to alcohol dependence is inherited
Lower rates of alcohol dependence amongst East Asians due to high prevalence of a less effective variant of aldehyde dehydrogenase (so get ‘flush reaction’- flushing, palpitations, nausea due to acetaldehyde)
Occupation
- Associated with certain occupations e.g. publicans, journalists, doctors, the armed forces and the entertainment industry
- Stressful work and socially sanctioned drinking combine to increase the risk
Social Background
- Difficult childhood, parental separation
- Educational achievement is often poor
- May be evidence of juvenile delinquency
Psychiatric Illness
- Associated with personality disorders, mania, depression, and anxiety disorders (particularly social phobia)
Mechanism of alcohol in the brain
- Primary target: GABA-A receptor/NMDA (glutamate) receptor
GABA-A receptor (inhibitory)
Acutely: alcohol boosts function -> anxiolysis, sedative
Chronically: alcohol reduces function as you develop tolerance – countered by alcohol boosting function
Glutamate-NMDA receptor (stimulatory)
Acutely: reduces function
Chronically: boosts function – associated with impaired memory
Withdrawal leads to:
- Increased glutamate-NMDA activity
- Decreased GABA activity
- This can lead to hyperactivity, resulting in cell death and seizures
Signs and symptoms
“Who’s in control? You or the drink?” – if they have to think about it, query dependence
Intoxication
Withdrawal:
~4-12 hours… Uncomplicated alcohol withdrawal syndrome (4-12 hours after last drink):
- S/S withdrawal: course tremor, sweating, insomnia, tachycardia, N&V, psychomotor agitation, anxiety, hallucinations (transitory visual, tactile to auditory), alcohol craving
~36 hours… Alcohol withdrawal syndrome with seizures (6-48 hours after last drink):
- S/S: grand-mal seizures (in 5-15% of withdrawals)
~48-72 hours… Delirium Tremens (1-7 days after last drink) – mortality of 5-10%:
- S/S: disorientation, anterograde amnesia, psychomotor agitation, hallucinations (Lilliputian hallucinations of little people or animals), hour by hour fluctuations (worse at night)
- If severe -> heavy sweating, fear, paranoid delusions, agitation, fever, sudden CV collapse
Dependence syndrome
Psychotic disorder
- Alcoholic hallucinosis (auditory hallucinations while drinking – often persecutory or derogatory)
- Lilliputian hallucinations
- Morbid jealousy (delusion that partner is unfaithful)
- Amnesia (i.e. anterograde amnesia in Korsakoff’s syndrome)
1 unit of ETOH
1 Unit ETOH
· 10mL/8g pure ethanol
· 25mL 40% proof alcohol
· Half a pint, small glass wine (125mL)
Investigations
Investigations – physical exam, bedside/basic observations, biochemical, imaging:
CAGE questionnaire (SCREENING TEST) -> ≥2 positive answers indicates you should do more investigation…
- Have you tried to cut down?
- Have you ever been annoyed by people suggesting that you have a problem with you drinking?
- Have you ever felt guilty about drinking?
- Have you ever needed a drink to get you going in the morning – eye opener?
Bloods: FBC (MCV), LFT, B12, folate, U&E, clotting screen, glucose, film (macrocytosis, no anaemia)
Urine: drug screen
Rating scales and Severity of Alcohol Dependence Questionnaire (SADQ)
1st line: AUDIT (Alcohol Use Disorders Identification Test) à if >20, move to 2nd line full assessment
- 0-7 = low risk 8-15 = increasing risk
- 16-19 = higher risk >20 = possible dependence SCREENING
- 2nd line: SADQ (Severity And Dependence Questionnaire)
AUDIT: https://cks.nice.org.uk/alcohol-problem-drinking#!diagnosisAdditional
AUDIT-PC – a shortened 5-question version of AUDIT
FAST (Fast Alcohol Screening Test) – a shortened 4-question version of AUDIT for use in A&E
- Scores 0 to 16; ≥3 = FAST positive
CIWA-Ar (Clinical Institute Withdrawal Assessment of Alcohol) scale for severity of withdrawal
APQ (Alcohol Problems Questionnaire) to assess nature and extent of problems from alcohol misuse
Full history (establish a timeline) and physical examination (stigmata of alcoholic disease):
- Lifetime pattern (age when first started, age regular drinking, age realised you had a problem…)
- Current consumption (describe a day’s drinking including approximate timings)
- Signs of dependence (see ICD-10 list)
- Social impacts (have you missed work, been in financial problems, relationships, etc.)
Management
Assessment and Preparation
- Motivation to Change
- Stages of Change Model: Pre-contemplation , Contemplation , Preparation, Action , Maintenance, Relapse
It is important to identify the type of support needed, for example:
**Short term: **reduce alcohol consumption
Medium term: undergo detox
Long term: attend college
Motivational Interviewing : Form of counselling which aims to empower the person to change
Detoxification : Allows metabolism and excretion of the substance whilst minimising discomfort
May be planned (after a period of preparation) or unplanned (after emergency admission)
Long-acting Benzodiazepines (e.g. chlordiazepoxide)
- Replace alcohol and prevent withdrawal symptoms
- Gradually withdrawn and stopped
Thiamine
- Prophylaxis against Wernicke’s encephalopathy
- Best given IV or IM
- Community (home) detox is used for uncomplicated dependency using a fixed-dosage reducing regime of benzodiazepines over 5-7 days
- Inpatient detox is used if there is a history of withdrawal fits, comorbid medical or psychiatric illness or if the patient lacks support at home
Relapse Prevention
- Psychological
- CBT
- Problem-solving therapies
- Group therapy (alcoholic anonymous)
Medical
- Acamprosate (anti-craving drug)
- Naltrexone
- Disulfiram (Antabuse) : Mimics the flush reaction to alcohol thereby making alcohol consumption unpleasant
Rehabilitation
- May be residential or day programme
- Residential programmes allow a break for people who have become submerged in the drinking community
- May be skills-based courses to help find employment
NICE Guidelines
- Refer children (10-15 years) to CAMHS and consider referral in 16-17 year olds
- Needs of family/ carers
- Offer a carer’s assessment if necessary
- Consider offering guided self-help for families and provide resources about support groups
- Consider offering family meetings, usually at least 5 weekly meetings
Establishing Goals
- Abstinence is the best treatment goal (but some may want a more moderate goal)
Principles of Interventions
- Carry out a motivational interview (explore problems related to drinking, encourage belief in ability to change)
- Offer interventions to promote abstinence as part of intensive structured community-based intervention for people with moderate-severe dependence who have limited social support, complex physical/ psychiatric comorbidities or not responded to initial community-based interventions
- If homeless, offer residential rehabilitation services for maximum 3 months
Routinely monitor outcomes
- Provide information about Alcoholics Anonymous, SMART Recovery and Change, Grow, Live (CGL)
- Care coordination: routine coordination by any staff involved in the care
- Case management: used to increase engagement in people at risk of dropping out of treatment (involves devising an individualised care plan)
- Referral to Specialist Alcohol Services for Planned Withdrawal if moderate-severe OR Alcohol Detoxification Programme (overseen by primary care if qualified)
- Specialist mental health services referral should be considered if mental health co-morbidities continue after 3-4 weeks of abstinence from alcohol
For Management in Primary Care
- Offer structured brief advice about alcohol consumption
- If no response, offer extended brief intervention with follow up (give up to 5 sessions)
- This may be helpful for people who are alcohol dependent but reluctant to accept a referral to specialist alcohol services
- For harmful drinkers and those with mild alcohol dependence
- Consider psychological intervention (e.g. CBT, behavioural therapy, social network and environment-based therapy)
- Focused specifically on alcohol-related conditions, behaviour, problems and social networks.
- Consists of 1 hour sessions for 12 weeks
- Offer Behavioural couples therapy (if regular partner present)
- If no response to the above, refer to specialist alcohol treatment service
- For harmful or dependent drinkers- offer prophylactic PO thiamine (Pabrinex)if they are malnourished or at risk of malnourishment
- If in secondary care and no response to the above or pharmacological treatment is requested, offer the following alongside psychological therapy:
Acamprosate (anti-craving)
Naltrexone
Interventions for Assisted Alcohol Withdrawal
- If > 15 units/ day or > 20 on AUDIT, consider offering:
- Community-based assisted withdrawal (best option)
- This can be done through organisations like CGL
- Usually 2-4 meetings in the first week
- If complex, may need up to 4-7 days per week over a 3-week period
- Should include a drug regimen and psychosocial support including motivational interviewing
Management in Specialist Alcohol Services if concerns about community-based
- Consider inpatient assisted withdrawal if ≥ 1 of the following:
- > 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
Drug Regimens for Assisted Withdrawal
- Consumption of more than 10 units a day for more than 10 days is an indication for prescribing a reducing regime.
- Fixed dose or symptom-triggered regimen
- Preferred medication: chlordiazepoxide OR diazepam
- If liver impairment (cirrhosis), consider lorazepam or oxazepam (limited hepatic metabolism)
- Titrate initial dose based on severity of alcohol dependence/ daily alcohol consumption
- Gradually reduce dose over 7-10 days
- This will be longer in concurrent benzodiazepine withdrawal treatment required (up to 3 weeks)
- Give no more than 2 days medication at a time (instalment dispensing) with community-based withdrawal
After Successful Withdrawal
Consider:
- PO Acamprosate or Naltrexone with individualised psychological intervention
- Consider disulfiram if above options are unsuccessful/ unacceptable
- Acamprosate: usually started at 1998mg/day (if weigh < 60kg, 1332mg)
- Naltrexone: usually started at 25mg/day with aim for maintenance dose at 50mg/day
- Disulfiram: start treatment at least 24 hours
- Usually prescribed for up to 6 months
- Carry out thorough medical assessment to establish baseline before starting medication (including U&E and LFTs)
Wernicke’s Encephalopathy
Start those at high risk or with suspected Wernicke’s thiamine:
- 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
Offer parenteral (IV/IM) thiamine to those with suspected Wernicke’s encephalopathy
- Give for at least 5 days unless Wernicke’s is excluded
- PO thiamine treatment should follow parenteral therapy
Offer parenteral thiamine followed by PO thiamine to those entering planned assisted alcohol withdrawal
For those with Wernicke-Korsakoff syndrome offer:
- Supported independent living for those with mild cognitive impairment
- Supported 24-hour care for those with moderate-severe cognitive impairment
Acute Alcohol Withdrawal
Pharmacological treatment to treat symptoms of withdrawal
- Consider chlordiazepoxide
- Alternative: clomethiazole
NOTE: withdrawal symptoms are worst within the first 48 hours and take 3-7 days after the last drink to completely disappear
Delirium Tremens
- 1st Line: PO Lorazepam
If symptoms persist, offer IV lorazepam or haloperidol
- Alternative: chlordiazepoxide
- IV Thiamine
Alcohol Withdrawal Seizures
Consider fast-acting benzodiazepine (e.g. Lorazepam) to reduce the likelihood of future seizures
Offer advice on local support services
Complications
Physical
- Liver: alcoholic hepatitis, cirrhosis, ascites, hepatic encephalopathy
- GI: pancreatitis, oesophageal varices, gastritis, peptic ulceration
- Neurological: peripheral neuropathy, seizures, dementia
- Cancers: bowel, breast, oesophageal, liver
- Cardiovascular: hypertension, cardiomyopathy
- Blood: macrocytic (megaloblastic) anaemia (folate deficiency), microcytic anaemia (blood los from GI tract), vitamin deficiencies, increased triglycerides leading to increased cardiovascular disease complications, neutropenia (trapping of neutrophils in enlarged spleen)
- Head injuries/ accidents
- Foetal alcohol syndrome
Psychological
- Depression, anxiety, self-harm and suicide
- Amnesia due to intoxication
- Cognitive impairment- either alcoholic dementia or Korsakoff syndrome
- Alcoholic hallucinosis- auditory hallucinations in clear consciousness (often persecutory or derogatory)
- Morbid jealousy- overvalued idea or delusion that a partner is unfaithful
Wernicke-Korsakoff
Wernicke’s Encephalopathy
- Caused by acute thiamine deficiency
TRIAD:
- Confusion
- Ataxia
- Ophthalmoplegia
MEDICAL EMERGENCY -> Parenteral Thiamine
Korsakoff Psychosis
- Irreversible anterograde amnesia
- Patient can register new events but cannot recall them within a few minutes
- Patients may confabulate to fill the gaps in their memory
- This is classically accompanied by apathy and loss of insight into difficulties.
- On neuro-imaging there is destruction of the mammillary bodies.
Social
Unemployment, poor attendance and performance at work, domestic violence, separation, divorce
DRINK-DRIVING- always ask alcoholics about this
Prognosis
Prognosis
Mild alcohol use disorders often remit as young adults assume additional responsibilities
More severe alcohol use is a chronic, relapsing condition, may progress from impulsivity to compulsivity, 5-10% die from withdrawal
PACES
Tell them not to go cold turkey immediately - will slowly wean them off
We believe you are suffering from alcohol use disorder, which means you are exhibiting a pattern of alcohol use that is causing physical, mental, social and/or occupational problems.
Consuming excessive alcohol can indicate some deeper issues that need resolving, but is also an issue in and of itself that needs addressing too.
We will take a biopsychosocial approach, which means we will be addressing the needs of your body, mind and social life:
For your body, we first need to address the deficiency in thiamine (which is also called vitamin B1) by giving you some thiamine tablets. We can also give you some medication called diazepam, which is a benzodiazepine, to help with your symptoms of withdrawal. After you have overcome the withdrawal, we can give you some medication to help you not want another drink, such as acamprosate. It is also essential that we get you exercising regularly, sleeping well and eating well to better manage stress and to restore better health in your body.
For your mind, we need to address the issues that were causing you to want to drink so much in the first place. Individual and group CBT sessions on a weekly basis for 12 weeks is what we would recommend to address this. In these sessions, we can also figure out some healthier coping mechanisms for dealing with stress.
Socially, attending support groups, such as Alcoholics Anonymous, can introduce you to people with similar issues and those who have also overcome this struggle. This helps people see that it is possible to make it out the other side of this battle as a better and healthier person. We can also facilitate you reconnecting with your fam through some family therapy if you wish.
