RCGP SMAH 10 minute approach to alcohol Practice

RCGP SMAH 10 minute approach to alcohol Practice based learning session

Aims Identify alcohol related problems and make a treatment plan in a primary care setting

Overview of the session 14. 00 What does alcohol mean to you? 14. 15 How to diagnose alcohol problems 14. 45 Learning trios 15. 30 Coffee Break 15. 45 Medical Aspects 16. 45 Finish and Evaluation

What does alcohol mean to you? • Have you had any experiences with patients who drink? • Do you drink? • How does drinking affect you?

How to diagnose alcohol problems Screening tools Calculating alcohol units Brief Intervention

Alcohol Screening… …is a method of identifying alcohol consumption at a level sufficiently high to cause concern.

Screening tools in primary care AUDIT alcohol use disorder identification test FAST fast alcohol screening test AUDIT-C AUDIT alcohol consumption questions AUDIT-PC AUDIT primary care M-SASQ modified single alcohol screening question Coulton S, Drummond DC, James D, Godfrey C, Bland JM, Parrott S, Peters T: Opportunistic screening for alcohol use disorders in primary care: comparative study. British Medical Journal 2006 , 332: 511 -7. NICE public health guidance 24: Alcohol-use disorders: preventing harmful drinking, Evidence statement e 5. 1

AUDIT Developed by the WHO specifically for use in primary care, validated in more than 22 countries gold standard in screening tools Sensitivity 92% and specificity 94% to identify increased, higher risk and possible dependent drinking Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption. Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M. Addiction. 1993 Jun; 88(6): 791 -804.

AUDIT scores NICE/WHO Score DH Terminology 0 -7 Lower Risk 8 - 15 Increasing Risk Hazardous Drinking 16 - 19 Higher Risk Harmful Drinking 20 - 40 Possible Dependence

Clinical definitions AUDIT Score NICE/WHO Terminology 0 - 7 Lower Risk Within recommended limits 8 - 15 Hazardous Above recommended limits no significant harm Harmful Above recommended limits AND significant harm 16 - 19

Typology (general population) Do. H 2005

Physical health risks Condition Men Women Hypertension 4 x 2 x Stroke 2 x 4 x 1. 7 x 1. 3 x Pancreatitis 3 x 2 x Liver disease 13 x CHD Source: Safe. Sensible. Social: the next steps in the national alcohol strategy (HM Government, 2007)

What is Brief Intervention? can be anything from a short conversation to a number of sessions Brief interventions help the patient to understand: • What consequences likely to be • What they can do about it • What help is available

Who is Brief Intervention for? AUDIT Definition Intervention 0 -7 Lower risk Positive reinforcement 8 - 15 Hazardous Brief Intervention 16 - 19 Harmful Extended Brief Intervention 20 - 40 Further Assessment Possible dependence • Brief intervention is for hazardous and harmful drinking • Usefulness is limited for dependent drinking

Brief Interventions Brief Intervention Extended Brief Intervention Increasing Risk Higher Risk single consultation multiple consultations Brief structured advise Up to 45 minutes structured intervention Goal setting over time Consider further examination Physical examination and investigations Limited follow-up Structured follow up

Structure of Brief Interventions FRAMES Feedback (personalised) Responsibility (with patient) Advice (clear, practical) Menu (variety of options) Empathy (warm, reflective) Self-efficacy (boosts confidence) Bien, T. H. , Miller, W. R. and Tonigan, J. (1993) Brief interventions for alcohol problems: a review. Addiction 88, 315– 336.

Does brief intervention work? 1 in 8 individuals drinking at hazardous or harmful levels act on their doctors advice and moderate their drinking to low risk levels. This compares to 1 in 20 individuals offered smoking advice (1 in 10 when nicotine replacements are offered). Alcohol: No Ordinary Commodity - Research and Public Policy (Babor et al 2003)

Does more intervention help more? Brief Intervention: is often as effective as more extensive treatments should not substitute for specialist treatment Might serve as an initial treatment for severely dependent Bien, T, Miller, W. R. and Tonigan, J. S. Brief interventions for alcohol problems: A review. Addiction 88: 315 -336, 1993. Moyer, A. , Finney, J. , Swearingen, C. and Vergun, P. Brief interventions for alcohol problems: A meta-analytic review of controlled investigations in treatment-seeking and non-treatment seeking populations. ddiction 2002 A Mar; 97(3): 279 -92.

Calculating units of alcohol Litres x ABV = Units Examples: 1 Litre of 4% lager = 4 units 0. 75 Litres of 12% wine = 9 units

Adults visiting GP Requesting help with alcohol problem Initial Screening Tools New Registration FAST Other health complaint AUDIT - C . 38 D 4 . 388 u Positive Result Negative Result Full Screen AUDIT Score 20+ . 38 D 3 Referral to Specialist Services 8 Hk. G Full Assessment AUDIT Score 16 -20 . 38 D 3 No action AUDIT Score 8 -15 . 38 D 3 Extended Brief Advice . 38 D 3 Brief Advice 9 k 1 B AUDIT Score 0 -7 9 k 1 A © Department of Health 2008

? Question time

Learning trios In groups of 3 you will take turns to be the GP/practitioner, patient and observer in role play – each person will have a go at being all three The patient and the GP will each play the character identified in the case given to them on the card The GP will deliver the AUDIT and undertake alcohol unit calculation The GP’s role is to respond and deliver a “brief intervention” to the patient if appropriate The Observer’s role is to note what helps and hinders the interactions between GP and Patient and then feedback to the GP and Patient in the five remaining minutes before swapping roles The exercise is completed when all members have had an opportunity to play GP, patient and observer

Learning trios Brief intervention exercise • Include an AUDIT assessment • Decide what level of intervention is appropriate for your case • Conduct a brief intervention if appropriate

Learning trios Feedback How did you feel that went? Any difficulties? Any anticipated problems?

Tea break Next session 15. 45 Medical Aspects of alcohol misuse

Medical Aspects Investigations Detoxification Medication Risks

Case Scenario A 36 year old man attends your surgery on a Friday afternoon. Mildly intoxicated. PC: He says that he is dependent on alcohol and will go into withdrawal soon as he ran out of money to buy alcohol. He requests an alcohol detoxification. O/E: Overall well, no signs of malnourishment. No signs of alcohol withdrawal

Case Scenario A 46 year old woman attends your surgery. PC Feeling unwell in the morning, vomiting at times increasing memory problems O/E Looks malnourished, without any specific findings. BP 155/90, pulse 90. Liver slightly enlarged. As you have no idea what is going on, you request a blood test: FBC, U&E, LFTs, TFTs. All come back as normal apart from the LFTs, which are slightly raised (<2 x normal).

Case scenario A 25 year old man attends your surgery. He is drunk to a degree that he could not find your consultation room initially. He requests a sick note as he is an alcoholic.

Investigations Dependency makes physical harm caused by alcohol more likely but a substantial amount of harmful drinking patients will develop medical problems Like in coronary heart disease, a low risk score does not guarantee safety.

Investigations Simple questionnaire-based screening tools are more effective to identify problematic drinking FBC (anaemia and raised MCV) LFT (consider GGT)

Abnormal blood tests – what now? NICE recommends: Abnormal LFTs – exclude alternative causes of liver disease Refer to a specialist to confirm a clinical diagnosis of alcohol-related liver disease. National Institute of Clinical Excellence: CG 100 Alcohol-use disorders: physical complications. Published May 2010

GGT only elevated in 30% heavy drinkers up to 50% of all raised GGT is due for other reasons less likely to be elevated in young people, episodic drinkers, women A possible tool in monitoring

Physical signs of alcohol misuse Peripheral neuropathy Signs of chronic liver disease Neurological symptoms Proximal myopathy Cardiomyopathy Enteropathy Signs of withdrawal

Why assess dependence? … because it is dangerous not to! • Sudden stop of drinking may result in developing serious and life threatening conditions such as withdrawal fits, delirium tremens and Wernicke’s encephalopathy. • Non-dependent drinkers can usually cut down and reduce associated problems • Dependent drinkers (by definition) find reducing more difficult. • Dependent drinkers generally need assistance to stop drinking

Dependent vs harmful drinkers AUDIT > 16 requires further assessment AUDIT score of >35 or >50 U per day makes dependence likely Need for medically assisted withdrawal and assessment of co-morbidity SADQ

Quantifying dependency AUDIT SADQ Sleep duration Eye opener Withdrawal Units/day 16+ <3 normal - - <15 Mild 16+ <15 8+ hrs - + <15 Moderate 20+ 15 -30 6 -8 hrs + ++ 15 -30 Severe 20+ 30+ 4 -6 hrs ++ +++ 30+ Harmful Dependence

Who needs detoxification? Use SADQ! • SADQ – establish severity of dependency • 20 item questionnaire • Score correlates with expected severity of withdrawal Score Severity of dependency 0 -3 No dependency 4 -19 Mild 20 -30 Moderate 31+ Severe Stockwell, T. , Sitharan, T. , Mc. Grath, D. & Lang, . (1994). The measurement of alcohol dependence and impaired control in community samples. Addiction, 89, 167 -174.

A sobering thought…. . Detoxification is but one event in a continuing process It is a technical step between preparation and aftercare As a stand alone treatment can do more harm than good Detoxification from opiates and alcohol are two very different events Detoxification from opiates is uncomfortable, but fairly safe, whilst detoxification from alcohol is potentially dangerous, and can be permanently disabling or fatal

Who doesn’t need detoxification? • • • Generally <15 units/day (M) or 10 units/day (F) No recent withdrawal symptoms No drinking to prevent withdrawal Occasional binges lasting <1 week SADQ (Severity of Alcohol Dependence Questionnaire) < 4

Where can detoxifications take place? General Hospital Psychiatric Hospital Non statutory rehab or detoxification unit Community § Community detoxification shows similar outcomes to inpatient – 75% successful in community § Community setting preferred by most patients § Accessibility and trust in practitioner is key advantage § Cost advantage Stockwell T, Bolt L, Milner I, Russell G, Bolderston H, Pugh P (1991). Home detoxification from alcohol; its safety and efficacy in comparison with inpatient care. Alcohol and Alcoholism; 26(5 -6): 645 -650. Finney J, Hahn A, Moos R (1995). The effectiveness of inpatient and outpatient treatment for alcohol abuse: the need to focus on mediators and moderators of setting effect. Addiction; 91(12): 1773 -1796

Alcohol Withdrawal Syndrome (AWS) • • Autonomic over-activity and hyperactivity Anxiety and tremor Nausea and vomiting Sweating Tachycardia Hypertension Pyrexia

Progression of AWS

Complications of AWS • Withdrawal seizures • Delirium Tremens • Wernicke’s encephalopathy and alcohol confusional withdrawal syndromes • Severe depression/suicide • Cardiovascular catastrophe (CVA, MI) Beware the older patient…

NICE guidelines on Detoxification Acute alcohol withdrawal For people in acute alcohol withdrawal with, or who are assessed to be at high risk of developing, alcohol withdrawal seizures or delirium tremens, offer admission to hospital for medically assisted alcohol withdrawal. National Institute of Clinical Excellence: CG 100 Alcohol-use disorders: physical complications (CG 100). Published May 2010

Medication Harm reduction Thiamine, Vit B Costrong Detoxification Chlordiazepoxide, Diazepam, Carbamazepine Relapse prevention or controlled reduction Naltrexone Nalmefene Disulfiram (Antabuse®) Acamprosate

Thiamine Offer prophylactic oral thiamine to harmful or dependent drinkers: • if they are malnourished or at risk of malnourishment or • if they have decompensated liver disease or • if they are in acute withdrawal or • before and during a planned medically assisted alcohol withdrawal. National Institute of Clinical Excellence: CG 100 Alcohol-use disorders: physical complications. Published May 2010

Community Detoxification Examples of a community detoxification regime: Total daily dose should be given in three to four divided doses Chlordiazepoxide Diazepam Day Total daily dose 1 120 mg 1 40 mg 2 100 mg 2 35 mg 3 80 mg 3 30 mg 4 60 mg 4 20 mg 5 40 mg 5 15 mg 6 20 mg 6 10 mg 7 5 mg

Naltrexone Recommended by NICE, but not licensed for controlled reduction 50 mg tablet once daily Opioid antagonist Can be used together with Acamprosate or on its own

Nalmefene Similar mechanism to Naltrexone Licensed in the UK to support controlled reduction PRN up to once daily

Acamprosate (Campral®) Well tolerated reduces craving after a detoxification and might help with cutting down alcohol intake 333 mg two tablets tds (reduced if < 60 kg) CI: renal failure, decompensated cirrhosis patients should engaged in aftercare Varies in effectiveness between patients

Disulfiram (Antabuse®) Evidence for efficacy only if supervised Numerous contraindications Severe aversive reaction after any alcohol: flushing, palpitations, hypotension, vomiting, headache Should be initiated in consultation with specialist service

Case Scenario - review A 36 year old man attends your surgery on a Friday afternoon. Mildly intoxicated. PC: He says that he is dependent on alcohol and will go into withdrawal soon as he ran out of money to buy alcohol. He requests an alcohol detoxification. O/E: Overall well, no signs of malnourishment. No signs of alcohol withdrawal Would you do anything different now?

Case Scenario A 46 year old woman attends your surgery. PC Feeling unwell in the morning, vomiting at times increasing memory problems O/E Looks malnourished, without any specific findings. BP 155/90, pulse 90. Liver slightly enlarged. As you have no idea what is going on, you request a blood test: FBC, U&E, LFTs, TFTs. All come back as normal apart from the LFTs, which are slightly raised (<2 x normal). Would you do anything different now?

Case scenario A 25 year old man attends your surgery. He is drunk to a degree that he could not find your consultation room initially. He requests a sick note as he is an alcoholic. Would you do anything different now?

? Question time

Competencies Understanding, awareness and knowledge Categories of problem drinking Screening tools, calculate units of alcohol Awareness of alcohol related health problems Skill Use AUDIT questionnaire Deliver brief interventions

Where can I learn more? RCGP Alcohol Certificate Alcohol Learning Centre

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