the gp curriculum states that gps in training must: understand the health and social burden of...

The GP curriculum states that GPs in training must: Understand the health and social burden of

excess alcohol consumption to the patient, the patient's family and the wider community

Be able to recognize the physical, psychological and social manifestations of alcohol problems

Be able to use screening tools to detect and assess alcohol problems in the practice populations

Be able to use brief interventions to assist patients consuming harmful amounts of alcohol to recognize that a problem exists, and cut down or stop drinking

Be able to recognize and manage alcohol-related emergencies such as fits, delirium and psychosis.

How is consumption categorised? Alcohol Misuse

Very broad term referring to any alcohol use likely to result in problems

Binge Drinking Consuming more than the recommended DAILY

allowance of alcohol

Alcohol Dependence Syndrome with specific symptoms. Must include three of

the following:○ Compulsion○ Loss of control○ Withdrawal○ Preoccupation with alcohol○ Persistent drinking○ Tolerance

The Burden of Alcohol 259 million primary care consultations/year 150,000 hospital admissions 15,000 to 22,000 deaths, mainly comprising

stroke, liver failure, cancer and suicide Half of all violent crime 1/3 of all domestic violence 17 million sick days Cost to the NHS: £1.7 billion Total cost to economy £2.4 billion Total revenue from duties... £13.3 billion

Health Effects of Alcohol misuse Injury – fights or accidents Increased cardiovascular morbidity Multiple gastrointestinal morbidities:

Liver damage – fatty liver, cirrhosis, failureGastritis and oesphagitisAcute and chronic pancreatitis

Anxiety & Depression, Dementia Diabetes & Macrocytic anaemia Sexual dysfunction Encephalopathy – Wernicke’s & Korsokoff’s

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Effects of high-risk drinking

Social Effects of Alcohol Misuse Relationship breakdown Social Isolation worsening MH problems Loss of employment, financial instability,

homelessness Stress on family, friends, partners, leading to

their own health and social consequences Motor accidents, loss of licence, DVLA

intervention:

Screening for Alcohol Misuse Traditional signs

Smell on breathTremor – hands, legs, tongueBloodshot eyes & dilated facial capillariesGI tract disordersFrequent accidentsInsomnia, anxiety, depressionSocial problems

Unexpected abnormal test results Formal screening tools

CAGEAUDIT

CAGE

Have you ever felt you should Cut down on your drinking?

Have people Annoyed you by criticizing your drinking?

Have you ever felt bad or Guilty about your drinking?

Have you ever had a drink first thing in the morning to steady your nerves or get

rid of a hangover (Eye-opener)?

AUDIT – Alcohol Use Disorders Identification Test

A tool to assess severity of drinking problem and the best method for treatment.

Not technically a screen 10 questions with

answers scoring 0-4,severity of drinking and appropriate treatment course based on score

Feel free to score yourself!

Intervention! Practices can provide specialist care as a NES (£££).

To do this, they must:Provide training for team members involvedRoutinely use alcoholism assessment toolsDevelop a register of all patients who admit that they are

alcohol misusersUndertake brief interventions and offer support to carry out

behavioural changeProvide detoxification in the community or home settingArrange follow-up treatment which might include counselling

services (in conjunction with or by referral to the local alcohol

services) or referral to a day programme or alcohol rehabilitation centre

Liaise with local specialist alcohol treatment services

Perform an annual review of the service including audit.

Alcohol education

Tell patient about risks of alcohol Explain nationally accepted limits of safe

alcohol use Advise not to use alcohol at all when

driving or operating heavy machinery

Readiness to Change

A simple question to ask patients – ‘on a scale of 1-10, how important is it to you to change your drinking’

1-4 indicates pre-contemplative 5-6 indicates thinking about change 7-10 suggests patient ready to take

action.

Simple advice Feedback—structured and personalized feedback

on risk and harm. Responsibility—emphasis on patient's personal

responsibility for change. Advice—Clear advice that change is needed. Menu—A menu for alternative strategies for making

a change in behaviour. Empathetic—delivered in an empathetic, non-

judgemental fashion. Self-efficacy—An attempt to increase the patient's

confidence in being able to change behaviour.

Alcohol Dependant Drinkers Stopping immediately may be harmful and

should not be advised Prescribe vitamins – thiamine and folate If a patient wants to stop drinking, referral to

the community alcohol team is indicated Home detoxification without alcohol team

support is not recommended

Contraindications to home detox Confusion or hallucinations History of previously complicated withdrawal (for example

withdrawal seizures or delirium tremens) Epilepsy or fits Malnourishment Severe vomiting or diarrhoea Increased risk of suicide Poor co-operation Failed detoxification at home Uncontrollable withdrawal symptoms Acute physical or psychiatric illness Multiple substance misuse Poor home environment

Alcohol Related Emergencies Three main ones you need to know:

FitsDelirium TremensWernicke’s/Korsakoff’s

Fits

Can happen due to excessive drinking but more commonly associated with withdrawal

Acutely need to be managed as any fit Patients who experience fits due to withdrawal

should be managed in an inpatient settling, whereas those who are continuing to drink can be managed as an OP once other causes are excluded.

Delirium Tremens

Syndrome characterised by the following:Delirium, often worse at nightClouding of consciousness; disorientationAgitationHallucinations – typically visual, often frighteningAutonomic dysfunction – hypertension, fever etc

15% mortality rate Treatment of choice - Benzos

Wernicke’s/Korsokoff’s Caused by thiamine deficiency Wernicke’s is a reversible encephalopathy

characterised by:Acute confusional stateOpthaloplegiaAtaxiaPeripheral neuropathy

Untreated, will progress to irreversible Korsokoff’s psychosis:Antero & retrograde amnesiaConfabulation

Thanks for Listening!