Alcohol problems in primary care

1. Alcohol problems in primary care Naomi Rundle GPST

2. Aims and objectives • Introduction • Harmful drinking and alcohol dependence • Identification and assessment of alcohol problems • Management principles • Cases and questions • Summary

3. Curriculum statement 15.3 – Drug and Alcohol Problems • Use appropriate screening tools • Differentiate between harmful drinking and alcohol dependency • Have an awareness of the physical, psychiatric and social manifestations of alcohol • Have an understanding of treatment options

4. Introduction • In England 6% of 16-74 year olds are dependant on alcohol (9% of men and 4% of women) • Around 24% of adults consume alcohol to levels that are potentially or actually harmful to their health • In 2009 there were 8664 alcohol related deaths in the UK

5. Recommended alcohol limits • Men – 21 units/week (no more than 4 units in any 1 day) • Women – 14 units/week (no more than 3 units in any 1 day)

6. Harmful drinking • A pattern of alcohol use associated with damage to the physical or mental wellbeing of the user. • Hazardous drinking is a pattern of consumption that increases someone’s risk of harm

7. Alcohol dependence • Characterised by craving, tolerance, a preoccupation with alcohol and continued drinking in spite of harmful consequences.

9. Identification and assessment of alcohol problems • Who to screen and how? • Screening opportunities and clinical presentations where alcohol should be considered • Physical • Psychiatric • Social

10. Physical presentations Neuro: Seizures, falls, cerebellar ataxia, peripheral neuropathy Other: Gout, osteoporosis, macrocytosis, anaemia, thrombocytopenia, RTA, head injuries, trauma, malignancy CVS: AF, hypertension, IHD, CVD, Cardiomyopathy GI: ulcers, gastritis, pancreastitis, abnormal LFTs GU: impotence, infertility, emergency contraception

11. Psychiatric and social presentations • Depression • Anxiety • Cognitive/memory impairment • Hallucinations • Repeated self-harm • Domestic violence • Drug abuse • Unplanned pregnancy • Frequent sick notes • Financial/work difficulties

12. Screening tools • CAGE – quick, 4 parts, identifies dependant drinkers • AUDIT – ‘gold standard’ for identifying hazardous drinkers and dependency (NICE,2010) • SADQ – for assessment of severity of dependence • MCV and GGT are not routinely recommended for screening.

13. AUDIT

14. Diagnosis of alcohol problems • A score of 8 or more on the AUDIT tool suggests hazardous or harmful drinking • A score of 20 or more suggests dependency

15. Management • Further assessment of the problem • Pattern of alcohol use, alcohol-related problems • Co-drug use • Risk of harm to self/others • Co morbidities • Motivation or readiness to change • Social support • Relevant physical examination and investigations

16. Structured brief advice • For people with hazardous or harmful drinking 5-10 minutes of simple brief interventions • Can be done by different members of primary health care team • Information giving to allow people to make changes • Give clear advice, self help information, giving responsibility to the patient for change • drinkaware.co.uk and patient.co.uk

17. Specialist services • Useful for dependent drinkers or when SBA has failed • Local services (in house alcohol workers, cmht) • AA • These may offer extended interventions, CBT, self help and group support, or assisted alcohol withdrawal programmes

18. Assisted alcohol withdrawal • Should be done only as part of a broader treatment programme • More than 15 units/day and score of 20 or more on AUDIT tool should be considered for community based or inpatient based withdrawal programmes • Commonly a reducing dose of chlordiazepoxide • Unlikely to be successful without appropriate social and psychological support

19. Other management considerations • Driving • Legal duty to inform DVLA • Thiamine/B12 • Wernicke’s encephalopathy • Complication in alcohol dependent patients • 100mg bd of thiamine • 1-2 tablets of vitamin b co-strong TDS • Relapse prevention • May be overseen by GPs. • Commonly used drugs – acamprostate, naltrexone, disulfiram

21. Summary • Be aware of how alcohol problems may present in GP • AUDIT is gold standard screening tool • Structured brief advice may prevent harmful drinking • Assisted alcohol withdrawal should be done by trained professionals within an alcohol support programme • Remember to enquire about driving • Find out about services local to your practice

22. Case 1: detox • A 53yr old patient comes to see you to prescribe some librium. He drinks approx 20 units a day and lives alone. He says he has had it before and it makes him less shaky. He wants to cut down his alcohol use. • What issues does this raise? What would you do?

23. Case 2: Driving • A 40 yr old mother of 2 (14yr and 16yr) comes in and admits to drinking 2 bottles of wine a day starting at midday. She also admits to driving to pick her children up from school in the afternoon but says she is fine to drive and does not feel drunk. • What issues does this raise and what would you do/advise her?

24. Useful info • www.drinkaware.co.uk • NICE alcohol-use disorders, June 2010 • NICE alcohol depencence and harmful alcohol use, Feb 2011 • DVLA, www.dft.gov.uk/DVLA Any questions??