AKT Alcohol and substance misuse

1. AKT Alcohol and substance misuse And what the AKT wants us to know about it Katherine Argyle VTS 2014

2. Specific AKT curriculum points: Evidence-based screening, brief interventions for alcohol misuse Effective primary care treatments for alcohol misuse disorders Knowledge of the barriers to care for people who misuse alcohol or drugs Knowledge of the different forms of harmful alcohol and drug use and how this may present

3. Specific AKT curriculum points: Legal aspects relating to alcohol Physical consequences of alcohol abuse including cirrhosis, portal hypertension, oesophageal varices, vitamin deficiencies, Wernicke-Korsakof syndrome Signs and symptoms of drug/alcohol misuse, as well as the signs and symptoms of withdrawal

4. What is problem drinking?

5. Problem drinking Hazardous Harmful Alcohol Dependence

6. HAZARDOUS DRINKING: • Consuming over 40 g/day (5 units) alcohol on average doubles a man’s risk for: • Liver disease • HTN • Some cancers (for which smoking is a confounding factor) • Violent death • For women over 24 g/day (3 units) increases their risk of: • Liver disease and breast cancer.

7. HARMFUL DRINKING Drinking which actually causes physical harm Has an ICD-10 classification - a pattern of drinking that causes damage to physical (eg to the liver) or mental health (eg episodes of depression secondary to heavy consumption of alcohol)

8. DEPENDENCE A definitive diagnosis of dependence should usually be made only if three or more of the following have been present together at some time during the previous year: • A strong desire or sense of compulsion to take alcohol • Difficulty in controlling drinking in terms of its onset, termination or level of use • Physiological withdrawal state when drinking has ceased or been reduced ordrinking to relieve or avoid withdrawal symptoms • Evidence of tolerance • Progressive neglect of alternative pleasures or interests because of drinking and increased amount of time necessary to obtain or take alcohol or to recover from its effects • Persisting with alcohol use despite awareness of overtly harmful consequences

9. (Volume in ml/1000) x % abv What is this equation for?

10. (Volume in ml/1000) x % abv = The formula for calculating alcohol units One unit. in the UK usually means a beverage containing 8 g of ethanol

11. Q A 125ml glass of wine (13% abv) is the same as one 50ml measure of sherry (17.5% abv) True / False

12. A A 125ml glass of wine (13% abv) is the same as one 50ml measure of sherry (17.5% abv) False Wine (125/1000) x 13 = 1.625 units Sherry (50/1000) x 17.5 = 0.875

13. How many units in a pint of lager (4.8% abv)? Nb. 1 pint = 568ml

14. How many units in a pint of lager (4.8% abv)? 2.7 units

15. SIGN recommends: AUDIT AUDIT-C FAST CAGE plus 2 consumption questions PAT (in patients presenting to A&E with an alcohol related injury)

16. AUDIT 10 item questionnaire Maximum score is 40 Likely hazardous or harmful alcohol consumption = score 8 or more for men (7 in women) Likely alcohol dependence = 15 or more for men (13 for women) AUDIT-C is the abbreviated 3 question form used in GP

17. FAST • A 30 second version of AUDIT • 4 questions • The first question can rule out hazardous drinking • How often do you have 8 (6) or more drinks on one occasion? • Do remaining questions if Q1 answer is monthly or less than monthly

18. CAGE C Have you ever felt you should cut down on your drinking? A Have people annoyed you by criticizing your drinking? G Have you ever felt bad or guilty about your drinking? EEye opener: Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover? PLUS maximum daily and total weekly consumption

19. Paddington Alcohol Test (PAT) • Only for people who present with suspected alcohol associated injury (consider delayed attendance) or symptoms suggesting alcohol misuse: • What is the most you will drink in one day? IF >8 units (man) 6 units (woman): • Does this happen once a week, once a month or more than once a month? • Do you feel your current attendance in A&E is related to alcohol?

20. 0845 76 97 555 What is this number for?

21. 0845 76 97 555

22. What SIGN says: While most patients are factual about their drinking, the primary care team should recognise that some will under-report their consumption at times. Biological tests are useful when there is reason to believe that self reporting may be inaccurate. General Practitioners and other primary care health professionals should opportunistically identify hazardous and harmful drinkers and deliver a brief (10 minute) intervention. The intervention should, whenever possible, relate to the patient’s presenting problem and should help the patient weigh up any benefits as perceived by the patient, versus the disadvantages of the current drinking pattern.

23. Legal aspects • DVLA must be notified if there is dependence on or misuse of alcohol illicit drugs or chemical substances in the past three years • Harmful drinking – 6 months ban • Alcohol dependence – 12 months ban • Alcoholic Liver disease – forever ban • Alcoholic seizure – epilepsy guidelines apply

24. How much can you be fined if you don’t tell the DVLA about a medical condition which could affect you driving? Hmmmm.

25. How much can you be fined if you don’t tell the DVLA about a medical condition which could affect you driving? £1000

26. Alcohol withdrawal • Withdrawal 6-36 hours • Seizures 6-48 hours • DTs 48-96 hours • Cessation of drinking is unlikely to be complicated in milder dependence. Medication may not be necessary if: • the patient reports consumption is less than 15 units/day in men / 10 units/day in women • And reports neither recent withdrawal symptoms nor recent drinking to prevent withdrawal symptoms • Among periodic drinkers, whose last bout was less than one week long, medication is not needed

27. Community detoxification is an effective and safe treatment for patients with mild to moderate withdrawal symptoms. Management is with chlordiazepoxide 10mg tablets in the community Start at 90mg total day 1, 90mg day 2, 60mg day 3, 40mg day 4, 20mg day 5 If at risk of Wernicke-Korsakoff’s, need IM Pabrinex Otherwise give oral thaimine indefinitely (200-300mg)

28. Acamprosate Acamprosate is recommended in newly detoxified dependent patients as an adjunct to psychosocial interventions. Should be initiated by a specialist service Reduces cravings Not effective in all so should be reviewed Continue for 6-12 months if does help

29. Disulfaram Supervised oral disulfiram may be used to prevent relapse but patients must be informed that this is a treatment requiring complete abstinence and be clear about the dangers of taking alcohol with it. Causes an unpleasant reaction when taken with alcohol MUST by prescribed under specialist supervision

30. Questions What is the most appropriate advice to give a man with regards to alcohol intake?

31. Questions What is the most appropriate advice to give a man with regards to alcohol intake?

32. Your next patient is a 34-year-old man who is known to have an alcohol problem. He has drunk around 100 units per week for the past five years. He regularly misses meals and smokes 20 cigarettes per day. What vitamin supplementation, if any, should you recommend?

33. Your next patient is a 34-year-old man who is known to have an alcohol problem. He has drunk around 100 units per week for the past five years. He regularly misses meals and smokes 20 cigarettes per day. What vitamin supplementation, if any, should you recommend?

34. You are discussing alcohol intake with a middle-aged man who has just been discharged from hospital after an episode of acute pancreatitis. He currently drinks around 2 litres of cider (ABV 5%) a day. How many units is that a week?

35. The End