Professor Kevin MooreUCL Institute of Liver and Digestive Health University College London Alcohol and the Liver
Alcohol Misuse Newham University Trust
The Alcohol Problem within North Central and East London
Facts and Definitions Alcoholism – patients have a distinct physical desire to consume alcohol beyond their capacity to control it, regardless of all rules of common sense. 1 in 13 adults Alcohol misuse generally refers to people who do not display the characteristics of alcoholism, but still have a problem . Not as dependent as an alcoholic is; still retain some control over alcohol consumption. Alcohol is a factor in 1 in 25 deaths worldwide. Alcohol kills six people in Scotland every day.
What is the risk of alcohol misuse? • The risk of developing cirrhosis is 10-15%. • Most patients need to drink >100 units per week for >10 years to develop cirrhosis. • 50% of alcohol misusers have normal liver function tests. • 10% risk of chronic pancreatitis • 1.7-3.3 fold increase risk of death with >6 drinks/day
Risk of death in cirrhosis • 50% of patients with alcoholic cirrhosis who continue to drink are dead within 3 years. • 75% of with alcoholic cirrhosis who stop drinking are alive at 7 years.
Liver Function Tests • Full Blood count – high MCV, low platelet count • Liver Function Tests • An AST>ALT may signify cirrhosis or alcohol misuse • A high bilirubin should be of concern but is mildly elevated in Gilberts (5% of population). • A very high gamma GT should raise suspicion of alcohol misuse. • Gamma GT increases with fatty liver, and drugs. • An isolated gamma GT in the absence of alcohol misuse is rarely a cause for concern, except that it may indicate hidden alcohol misuse.
Other Liver Function Tests • HCV IgG and HBsAg • Autoantibodies • Ferritin – always very high in alcoholic hepatitis • HFE Genotyping • Coeliac antibodies • Alpha fetoprotein
What should we do? 1. Screen patients for alcohol misuse. Screening for alcohol misuse is taking place in North Central London and East London. AUDIT or FAST 2. What should GP’s do? You must offer a brief intervention, both verbally and ideally with a brief intervention leaflet. Risk of litigation.http://www.alcohollearningcentre.org.uk/eLearning/IBA • How effective is a brief intervention? 12% of patients will decrease their alcohol consumption following a brief intervention, but this may need to be repeated over time.
Detox • It is easy to detox patients, we simply admit, give them drugs and most are fine. However, there needs to be a long term plan of support and continued care. Use symptom triggered approach. • It is hard to prevent patients drinking again. • Clear medical advice • Alcohol liaison services • Alcoholics anonymous • Psychotherapy or psychological support • Drugs
What drugs can be used for detox? • Chlordiazepoxide. Problem with t½ prolonged with cirrhosis • Lorazepam for patients with liver disease. • Carbamezapine • Baclofen
Patients need to be heard • Some patients with alcohol misuse have a terrible background. • They need to be heard and listened to. • Are patients who are alcoholic always alcoholic? • There may be issues that need to be resolved so they can be “cured”.
Role of psychologists or psychotherapists? • Some patients have clear issues that need to be resolved. • Some patients benefit from counselling or psychotherapy. • Some people believe if you can get a patient to understand why they drink, they are less likely to drink. • Limited resources
What are the differences between alcohol misusers? • Some are alcoholic • Many simply drink too much. What you need to ask. • If you miss a drink do you develop shakes or start sweating? • Do you ever need a drink first thing in the morning? • Do you feel sick most mornings and start vomiting or retching? • Do you get nervous if you think you can’t get a drink that day?
What drugs help to prevent patients drinking again? • Acamprosate • Baclofen • Naltrexone or nalmefene • Disulphiram
Should I prescribe sleeping tablets to my patient with alcohol problems? • Patients who stop drinking often have trouble sleeping. • What is better? Benzodiazepine use and possible addiction or alcohol addiction? • What should I do? Warn patients and record warning. However, there are clear guidelines that make continued use difficult.
Conclusions • Alcohol misuse is the driver for rising deaths from liver disease in the UK. • Most deaths occur in the young (<60 years) • >50% of Alcohol misusers are NOT alcoholic, they just drink too much. Most accessible. • 50% patients with alcoholic cirrhosis are dead within 3 years if they continue to drink. • Brief intervention works in 12%, so use it.