Alcohol & Alcohol Related Problems

8/3/2019 Alcohol & Alcohol Related Problems

1/50

Dr. R.A.N.S. Rajapakshe

SHO Medicine

BH - Wathupitiwala


2/50

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 consumingalcohol & 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


3/50


4/50

Ethyl alcohol or ethanol the intoxicating substance

Ethanol is oxidized to Acetaldehyde by

ADH (Alcohol Dehydrogenase) in many tissuesMEOS( Microsomal Enzyme Oxidizing System) liver

Acetaldehyde is converted to Acetate 90% in liver

mitochondria

Acetate in blood oxidized by peripheral tissues to CO2&H2O


5/50

One Unit = 8g of absolute Alcohol

Blood alcohol concentration = 15- 20 mg/dl

Amount metabolized in 1 hour duration


6/50

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 ifdrinking 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


7/50

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.


8/50

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 dependencesyndrome


9/50

Homicide / AttemptedSuicide / AttemptedOther intentional injuries (i.e., interpersonal

violence)Domestic violenceSexual assaultUnprotected sexMotor vehicle accidentsOther accidents

DrowningBurns


10/50

Liver cirrhosis and other forms of alcohol-relatedliver disease

Hypertension and haemorrhagic strokeCancers of the mouth, larynx, pharynx and

oesophagusOther cancers, including breast cancerFoetal Alcohol Syndrome (FAS) and foetal alcohol

effects

Mental illness (Depression, Anxiety, Deliriumtremens , Memory problems) Alcohol Dependence Syndrome


11/50

Lower workplace productivity

Unemployment

To family & social networks

Truancy & school exclusion

Homelessness

Economic costs

Child abuse


12/50

CNS Epilepsy

Wernicke- Korsakoff syndrome

Polyneuropathy

CVS

Cardiomyopathy

Beriberi heart diseaseCardiac arrhythmias

Hypertension


13/50

Respiratory system

Chest infections

GIT-

Acute gastritis

CA of oesophagus/ large bowelPancreatic disease

Liver disease

Musculoskeletal system Acute/ chronic myopathy

Osteoporosis

Osteomalacia


14/50

Endocrine system

Pseudo Cushings syndrome

Haemopoietic system

Macrocytosis (direct toxic effect on bone marrow or

folate deficiency)Thrombocytopenia

Leucopenia

Metabolism Hypoglycaemia

Hyperlipidaemia

Hyperuricaemia (gout)

Obesity


15/50

Fetal Alcohol Syndrome (FAS) facial abnormality

low weight

low intelligence

over activity

Fetal AlcoholE

ffect (FAE

) children with a history of prenatal alcohol exposure but

with fewer than the full physical or behavioral

symptoms of FAS


16/50

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 ofscreening

Universal (nearly all patients attending PHC are screened) or

Targeted (specific groups screened)


17/50

Full AUDIT (10 items)

AUDIT-C (first 3 items of AUDIT)

FAST (1 item plus 3 further items depending onresponse to 1st item)

CAGE (4 items)

TWEAK (5 items)

SASQ (1 item)


18/50


19/50

Harmful

16-19

Hazardous

8-15

Low risk

1-7

Abstainers0

Possible dependence 20-40 Need specialist advice

Brief counseling/follow up

Simple structured advice

Positive reinforcement

No action indicated

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


20/50

Stands for AUDIT-consumption questionsConsists of first 3 items from the full AUDIT, q.v.

less timeA score of 5+ is indicative of hazardous or

harmful drinkingMen: 78% sensitivity & 75% specificityWomen: 50% sensitivity & 93% specificityAUDIT-C cannot be used to determine which

level of brief intervention is appropriate or if areferral 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


21/50

Using the full AUDIT as the criterion, FAST shows a sensitivity of 91% & a specificity of95%.


22/50

Ever felt you ought to Cut down on your drinking ?

Have peopleAnnoyed you by criticizing yourdrinking ?

Ever felt bad or Guilty about your drinking ?

Ever had anEye opener to steady nerves in the

morning ?

Yes to >2 quite good at detecting alcohol abuse &

dependence.

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


23/50

Have you an increased Tolerance of alcohol ? 2pts

Do youWorry about your drinking ? 2pts

Have you ever had alcohol as anEye opener in the

morning ? 1pts

Do you ever getAmnesia after drinking ? 1pts

Have you felt the need to K(c)ut down on yourdrinking ? 1pts

Score >2 suggests an alcohol problem

More sensitive than the CAGE in some populations

(E.g. Pregnant women)


24/50

Stands for SingleAlcohol Screening QuestionWhen was the last time you had more than Xdrinks in 1 day, where X=6 for women and X=8

for men

Never/ More than 12 months ago/ 3-12 monthsago/ Within the past 3 months

Within the past 3 months = +ve response

If +ve need to validate with Full AUDITSensitivity and specificity = 86% for detecting

hazardous drinking in past 3 months or alcohol

use disorder in past year

Equally efficient among men and women


25/50

Pattern of repeated self- administration of alcoholthat usually results in tolerance, withdrawal &

compulsive substance-taking behavior

Continued use of the substance despite significant

substance-related problems essential element


26/50

Rapid reinstatement of

syndrome on drinking after

period of abstinence

Subjective awareness

of compulsion to drink

A narrowing of

drinkingrepertoire

Primacy of

drinking over

other activities

Increased tolerance &

need for more alcohol

to achieve same

result

Withdrawal symptoms- bad

nerves, shakiness, black outs,delirium tremens

Relief/ avoidance ofwithdrawal by

further drinking


27/50

Unable to keep a drink limit

difficulty in avoiding getting drunkspending considerable time drinking

Missing meals

memory lapses, blackouts

Restless without drinkOrganizing day around drink

Trembling after drinking the day before

Morning retching & vomiting

Sweating excessively at nightWithdrawal fits

Morning drinking

Increased tolerance

Hallucinations, frank delirium tremens


28/50

Most serious withdrawal state

After 1 3 days of alcohol cessation

Symptoms

disorientation

agitationmarked tremor

visual hallucinations

Signs

sweatingtachycardia

tachypnoea

pyrexia


29/50

Complications

dehydration

infections

hepatic disease

Wernicke- Korsakoff syndrome


30/50

Any three of the following

Tremor of outstretched hands, tongue or eye lidsSweating

Nausea, vomiting or retching

Tachycardia or hypertension

Anxiety

Psychomotor agitation

Headache

InsomniaMalaise or weakness

Transient visual, tactile or auditory hallucinations or

illusions

Grand mal convulsions


31/50

General measures

Admit the Pt

Correct Electrolyte abnormalities & Dehydration

Tx any co- morbid illness E.g. Infection

In the absence of W K syndromeIV Thiamin 250mg daily for 3 5 days beware

In the presence of W K syndrome Anaphylaxis

IV Thiamin 500mg daily for 3 5 days

If Hx of withdrawal fits

Prophylactic Phenytoin/ Carbamazepin


32/50

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 15mg6H for 8 doses

Provide additional drugs when signs & symptoms arenot controlled


33/50

Population based approaches

Rising the price taxation

Licensing laws to limit hours when alcohol is

availableControl of advertising & media portrayal of alcohol

drinks

Controlling the sale limiting sales in shops

Restrictions on who may buy alcoholHealth education programmes


34/50

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/ abstinencetreatments of medical disabilities

resolution of interpersonal problems

dealing with practical dificulties

establishing new interest (finance, employment)


35/50

Try to involve partner in treatment plan

Plan longer term help

individual/ group counselling

AA meetings

Help for the family


36/50

Brief intervention

Motivational therapy through motivational

approach

Referral to lay services (Alcohol Anonymous)


37/50

Consist ofassessment of quantity of alcohol consumption

provision of information about hazards of alcohol

advice about abstinence / safe limits

Evidence shows effective approach for people whosedrinking 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


38/50

Patients who do not respond to brief interventionmore intensive psychological intervention

based on five stages of change

PRECONTEMPLATION

CONTEMPLATION

DETERMINATION/PREPERATION

ACTION

MAINTENANCE


39/50

In Pre-contemplation,

The person is unaware, unwilling, ortoo discouraged to change within

next six month.


40/50

In Contemplation,

The person is thinking aboutchanging a behavior within next six

months.


41/50

In Determination,

The person is seriously considering& planning to change a behavior

within 30 days & has taken stepstoward change.


42/50

InAction,

The person is actively doing thingsto change or modify behavior.


43/50

In Maintenance,

The person continues to maintainbehavioral change[for at least six

months] until it becomespermanent.


44/50

In Relapse,

The person returns to pattern ofbehavior that he/she has begun tochange & thus returns to one of thefirst three stages.


45/50


46/50

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 symptomsdermatitis urinary frequency

impotence peripheral neuropathy

toxic confusional states


47/50

CI- resent heart disease

significant suicidal ideationsevere liver disease

Naltrexone (50mg/day)

opioid antagonist

reduces the risk of relapse in to heavy drinkingreduces 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


48/50

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


49/50

Do not drink to drown your problems

One unit of alcohol is eliminated per hour, thereforespread drinking time

Food decreases absorption & therefore results in a lowerblood alcohol level


50/50

Kumar & Klark s Clinical Medicine 7th Edition

Oxford core texts Psychiatry 2nd Edition

Screening & brief alcohol interventions at primary

care - Professor Nick Heather (PPt) Drinking Responsibly:A Lifestyle Challenge on Campus

Michael hall (PPt)

Alcohol related problems - Dr Chris Madden GP VTS

SHO (PPt)

NRCFCPP Concurrent PermanencyPlanning

Curriculum stage of change

Alcohol & Alcohol Related Problems

Documents

Transcript of Alcohol & Alcohol Related Problems