Dr. R.A.N.S.

Rajapakshe SHO Medicine BH - Wathupitiwala

 Alcohol is a part of our society  21.2% of men & 3.3% of women is taking Alcohol

(WHO 2004)  67% of families has at least one member consuming alcohol & tobacco (WHO 2002)  24% of male deaths are relevant to alcohol (Dissanayake & Navarathna 1999)  The increase rate of alcohol users is higher among those in the threshold of youth.  Illicit brew???????  One of the countries with highest alcoholism level

 Ethyl alcohol or ethanol the intoxicating substance  Ethanol is oxidized to Acetaldehyde by  ADH (Alcohol Dehydrogenase) in many tissues  MEOS( Microsomal Enzyme Oxidizing System) liver  Acetaldehyde is converted to Acetate 90% in liver

mitochondria  Acetate in blood oxidized by peripheral tissues to CO2 &H2O

 One Unit = 8g of absolute Alcohol  Blood alcohol concentration = 15- 20 mg/dl  Amount metabolized in 1 hour duration

 21 U for men & 14 U for women/wk

No long term health risk  21-35 U(men) & 14- 24 U(women)/wk - Unlikely to be any long term health damage if drinking is spread throughout the wk  > 36 U(men) & >24 U(women)/wk Liable to damage to health  > 50 U(men) & >35 U(women)/wk Definite health hazard

 Problem Drinker  causes or experiences physical, psychological and/or social harm as a consequence of drinking  not physically addicted to alcohol  Heavy Drinkers  drink significantly more in terms of quantity and/or frequency than is safe to do so long term.

 Binge Drinkers  drink excessively in short bouts, usually 24 48 h long  separated by often quit lengthy periods of abstinence  overall monthly or weekly intake may be relatively modest  Alcohol Dependence  physical dependence on or addiction  alcoholism is replaced by alcohol dependence syndrome

Homicide / Attempted Suicide / Attempted Other intentional injuries (i.e., interpersonal violence) Domestic violence Sexual assault Unprotected sex Motor vehicle accidents Other accidents Drowning Burns

Liver cirrhosis and other forms of alcohol-related liver disease Hypertension and haemorrhagic stroke Cancers of the mouth, larynx, pharynx and oesophagus Other cancers, including breast cancer Foetal Alcohol Syndrome (FAS) and foetal alcohol effects Mental illness (Depression, Anxiety, Delirium tremens , Memory problems) Alcohol Dependence Syndrome

 Lower workplace productivity Unemployment To family & social networks Truancy & school exclusion Homelessness Economic costs  Child abuse

 CNS Epilepsy  Wernicke- Korsakoff syndrome  Polyneuropathy  CVS  Cardiomyopathy  Beriberi heart disease  Cardiac arrhythmias  Hypertension

 Respiratory system  Chest infections  GIT Acute gastritis  CA of oesophagus/ large bowel  Pancreatic disease  Liver disease  Musculoskeletal system  Acute/ chronic myopathy  Osteoporosis  Osteomalacia

 Endocrine system  Pseudo Cushing s syndrome  Haemopoietic system  Macrocytosis (direct toxic effect on bone marrow or folate deficiency)  Thrombocytopenia  Leucopenia  Metabolism  Hypoglycaemia  Hyperlipidaemia  Hyperuricaemia (gout)  Obesity

 Fetal Alcohol Syndrome (FAS)  facial abnormality  low weight  low intelligence  over activity

 Fetal Alcohol Effect (FAE)

children with a history of prenatal alcohol exposure but with fewer than the full physical or behavioral symptoms of FAS

Detect risky drinkers whose level of consumption

may not be apparent  Not sufficient to rely on obvious signs of heavy drinking (e.g. alcohol on breath, purple nose etc.)  Biochemical markers (GGT, MCV, CDT) are relatively expensive, intrusive & no more accurate than questionnaires  Short questionnaires are the most efficient way of screening  Universal (nearly all patients attending PHC are screened) or Targeted (specific groups screened)

 Full AUDIT (10 items) AUDIT-C (first 3 items of AUDIT) FAST (1 item plus 3 further items depending on

response to 1st item)

 CAGE (4 items)  TWEAK (5 items) SASQ (1 item)

Possible dependence 20-40

Need specialist advice

Harmful 16-19 Hazardous 8-15 Low risk 1-7 Abstainers 0

Brief counseling/follow up

Simple structured advice

Positive reinforcement

No action indicated

High sensitivity (92%) and specificity (94%) and is now used as a screening instrument all over the world

 Stands for AUDIT-consumption questions

Consists of first 3 items from the full AUDIT, q.v.

less time A score of 5+ is indicative of hazardous or harmful drinking Men: 78% sensitivity & 75% specificity Women: 50% sensitivity & 93% specificity AUDIT-C cannot be used to determine which level of brief intervention is appropriate or if a referral for treatment is called for. In the event of a positive result on AUDIT-C, decisions should be based on clinical judgement or administration of the full AUDIT

Using the full AUDIT as the criterion, FAST shows a sensitivity of 91% & a specificity of 95%.

 Ever felt you ought to  Have people

Cut down on your drinking ?

Annoyed you by criticizing your Guilty about your drinking ?

drinking ?
 Ever felt bad or  Ever had an

Eye opener to steady nerves in the

morning ?
Yes to >2 quite good at detecting alcohol abuse &

dependence. Sensitivity 43% - 94% & Specificity 70% - 97%

 Have you an increased  Do you

Tolerance of alcohol ?

2pts

Worry about your drinking ? 2pts  Have you ever had alcohol as an Eye opener in the
morning ? 1pts

Amnesia after drinking ? 1pts  Have you felt the need to K(c)ut down on your
 Do you ever get

drinking ? 1pts
 Score >2 suggests an alcohol problem  More sensitive than the CAGE in some populations

(E.g. Pregnant women)

Stands for Single Alcohol Screening Question  When was the last time you had more than X

drinks in 1 day , where X=6 for women and X=8 for men Never/ More than 12 months ago/ 3-12 months ago/ Within the past 3 months  Within the past 3 months = +ve response If +ve need to validate with Full AUDIT Sensitivity and specificity = 86% for detecting hazardous drinking in past 3 months or alcohol use disorder in past year Equally efficient among men and women

 Pattern of repeated self- administration of alcohol

that usually results in tolerance, withdrawal & compulsive substance-taking behavior

 Continued use of the substance despite significant

substance-related problems essential element

Rapid reinstatement of syndrome on drinking after period of abstinence

Subjective awareness of compulsion to drink

Relief/ avoidance of withdrawal by further drinking

A narrowing of drinking repertoire

Withdrawal symptoms- bad nerves, shakiness, black outs, delirium tremens Increased tolerance & need for more alcohol to achieve same result

Primacy of drinking over other activities

 Unable to keep a drink limit  difficulty in avoiding getting drunk  spending considerable time drinking  Missing meals  memory lapses, blackouts  Restless without drink  Organizing day around drink  Trembling after drinking the day before  Morning retching & vomiting  Sweating excessively at night  Withdrawal fits  Morning drinking  Increased tolerance  Hallucinations, frank delirium tremens

 Most serious withdrawal state  After 1

3 days of alcohol cessation  Symptoms

 disorientation  agitation  marked tremor  visual hallucinations

 Signs  sweating  tachycardia  tachypnoea  pyrexia

 Complications  dehydration  infections  hepatic disease  Wernicke- Korsakoff syndrome

Any three of the following  Tremor of outstretched hands, tongue or eye lids  Sweating  Nausea, vomiting or retching  Tachycardia or hypertension  Anxiety  Psychomotor agitation  Headache  Insomnia  Malaise or weakness  Transient visual, tactile or auditory hallucinations or illusions  Grand mal convulsions

 General measures  Admit the Pt  Correct Electrolyte abnormalities & Dehydration  Tx any co- morbid illness E.g. Infection  In the absence of W K syndrome


IV Thiamin 250mg daily for 3 IV Thiamin 500mg daily for 3

5 days 5 days

beware
Anaphylaxis

 In the presence of W


K syndrome

 If Hx of withdrawal fits


Prophylactic Phenytoin/ Carbamazepin

 Specific drug treatment one of following PO  Diazepam 10 20 mg  Chlordiazepoxide 30 60 mg

Repeat 1 h after last dose depending on response  Fixed- schedule regimens

 Diazepam 10mg 6H for 4 doses, then 5mg 6H for

8 doses OR Chlordiazepoxide 30mg 6H for 4 doses, then 15mg 6H for 8 doses

Provide additional drugs when signs & symptoms are not controlled

 Population based approaches  Rising the price taxation  Licensing laws to limit hours when alcohol is available  Control of advertising & media portrayal of alcohol drinks  Controlling the sale limiting sales in shops  Restrictions on who may buy alcohol  Health education programmes

 Review with the patient  extent of drinking  evidence for dependence  alcohol related disabilities  Arrange withdrawal of alcohol  Treat urgent medical / psychiatric illnesses  Set attainable goal for  control of drinking/ abstinence  treatments of medical disabilities  resolution of interpersonal problems  dealing with practical dificulties  establishing new interest (finance, employment)

 Try to involve partner in treatment plan  Plan longer term help  individual/ group counselling  AA meetings Help for the family

 Brief intervention  Motivational therapy through motivational

approach Referral to lay services (Alcohol Anonymous)

 Consist of  assessment of quantity of alcohol consumption  provision of information about hazards of alcohol  advice about abstinence / safe limits  Evidence shows effective approach for people whose

drinking is not yet severe

 reduce consumption as a result  heavy drinkers twice more likely to cut down

 Brief interventions are delivered by generalists in community settings, e.g. GPs, practice nurses, health visitors, dieticians and other primary health care professionals in the normal course of their work

 Patients who do not respond to brief intervention  more intensive psychological intervention  based on five stages of change

PRECONTEMPLATION CONTEMPLATION DETERMINATION/PREPERATION ACTION MAINTENANCE

In Pre-contemplation, The person is unaware, unwilling, or too discouraged to change within next six month.

In Contemplation, The person is thinking about changing a behavior within next six months.

In Determination, The person is seriously considering & planning to change a behavior within 30 days & has taken steps toward change.

In Action, The person is actively doing things to change or modify behavior.

In Maintenance, The person continues to maintain behavioral change[for at least six months] until it becomes permanent.

In Relapse, The person returns to pattern of behavior that he/she has begun to change & thus returns to one of the first three stages.

Disulfiram (100-200mg/day)  cause unpleasant acetaldehyde intoxication & histamine release  experience flushing, headache, choking sensation, rapid pulse & anxiety  occasional risk of cardiac irregularities or rarely cardiovascular collapse  SE- metallic taste GI symptoms dermatitis urinary frequency impotence peripheral neuropathy toxic confusional states

CI- resent heart disease

significant suicidal ideation severe liver disease Naltrexone (50mg/day)

 opioid antagonist  reduces the risk of relapse in to heavy drinking  reduces the frequency of drinking

 Acamprosate (1-2g/day)  acts on GABA, Norepinephrine & Serotonin receptors  reduces drinking frequency  Fluoxetine  pts with both depressive illness & alcohol dependance

 Daily maximum 3 units for men  2 units for women  To help achieve this  use a standard measure  do not drink during the day time  have alcohol free days each week  Remember  Health can be damaged without being drunk  Regular heavy intake is more harmful than

occasional binges

 Do not drink to drown your problems  One unit of alcohol is eliminated per hour, therefore

spread drinking time  Food decreases absorption & therefore results in a lower blood alcohol level

7th Edition  Oxford core texts Psychiatry 2nd Edition  Screening & brief alcohol interventions at primary care - Professor Nick Heather (PPt)
 Kumar & Klark s Clinical Medicine
 Drinking Responsibly:A Lifestyle Challenge on Campus

Michael hall (PPt)  Alcohol related problems - Dr Chris Madden GP VTS SHO (PPt) NRCFCPP Concurrent Permanency Planning Curriculum stage of change