Alcohol

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Alcohol
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In wine there is health Pliny the Elder (AD
23) Throughout history wine has been described
as the most healthful and most hygienic of
beverages Louis Pasteur (18221895) In the late
1800s Dr William Osler described alcohol
asthe most valuable medicinal agent and the
milk of old age Alcohol is the anaesthesia by
which we endure the operation of life.George
Bernard Shaw (18561950)
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Patients and Alcohol (1)

• Many common presentations to GPs will have
  alcohol as an underlying cause or as a
  contributory factor
• Research estimates that I in 6 GP patients are
  drinking at levels that affect their health
• Because alcohol, and heavy drinking, is so well
  accepted in the Australian community many health
  and social problems that are associated with
  alcohol are overlooked or go unrecognised.

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Patients and Alcohol (2)

• It is estimated that there are over 500,000
  alcohol dependent people in Australia
• Only 10 receive some form of treatment,
  including self help groups
• Only 1 are prescribed anti-craving drugs
• (in contrast to the estimated 30 of opioid
  dependent people who are in treatment)

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Rationale for GP Involvement

• patient preference Research shows that
  patients expect and want their GP to ask about
  lifestyle issues such as their drinking. Patients
  are more comfortable about this than GPs
• evidence of efficacy There is 25 years of
  research evidence that shows that GP treatment
  works well in addressing alcohol-related problems
  
• size of problem Alcohol-related problems impact
  significantly on the workload of GPs.

• There is a strong case for GP involvement with
  patients drinking behaviour. It includes

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Common Alcohol-related GP Presentations

• These are examples of common presenting problems
  among patients who are not likely to be alcohol
  dependent, but rather who drink more than
  recommended either on occasion or regularly.
• GP intervention to reduce patient drinking levels
  to low risk levels
• a) works and
• b) improves clinical and costeffectiveness of
  treatment.

• Examples include
• GI problems (esp. Monday morning)
• high blood pressure
• sleep disorders (esp. insomnia)
• injuries
• anxiety problems
• depression
• marital discord
• child abuse.

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Acute Alcohol-related Harms

• Physical injury and psychological harms and death
  arise from
• falls, physical assaults, sexual assaults, DV,
  RTA, occupational and machinery injuries, fires,
  drowning, child abuse, unprotected sex leading to
  STDs, overdose, comorbidity, dehydration, sleep
  disturbances, raised blood pressure, shortness of
  breath.

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Patient Focus

• Traditionally, health concerns about alcohol were
  directed at middle-aged and older men
• Increasingly, there are health concerns about the
  drinking patterns of young people
• Women's drinking patterns are also increasingly
  risky.

GP attention needs to be directed to possible
alcohol-related problems with young people, women
and also older age groups.
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What Patients Think
Alcohol
adapted from Wallace Haines (1984)
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Alcohol

• Still the most popular drug
• over 80 of population drinks
• 8 drink daily, peak in males 60 yrs (23). 40
  drink weekly
• At-risk drinking now defined by NHMRC as
• risks of harm in the long term (chronic harm)
• risks of harm in the short term (acute harm)
• Important role for GPs in giving advice
  consistent with NHMRC risk levels.

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Australias Drinking Guidelines

• Australias drinking guidelines were developed by
  the NHMRC.
• See www.nhmrc.gov.au

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Who drinks?
Age
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A Standard Drink
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Risky Drinking Levels
(for chronic harm)
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High and Low Risk Drinking Levels For Short- and
Long-Term Harm
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NHMRC Alcohol Guidelines (2001)
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Risky Drinking Patterns

• 34 of drinkers (gt14 years) put themselves at
  risk of alcohol-related harm, in the short term,
  on at least one occasion over 12 months
• Over one in 10 females aged 1419, and over one
  in six males aged 2029, put themselves at risk
  of alcohol-related harm, in the short term
• 60 of 2029 year olds drink in a risky manner
• 12 do so at least weekly.

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Drinking Patterns for Acute Harm
ABSTAINERS

• High Risk
• M gt11 SD p.d.
• F gt7 SD p.d.
• Risky
• M gt7 SD p.d.
• F gt5 SD p.d.
• Low Risk
• M 6 SD p.d.
• F 4 SD p.d.

High Risk M gt 11 SD p.d. F gt 7 SD p.d.
LOW RISK
RISKY / HIGH RISK
Risky M gt 7 SD p.d. F gt 5 SD p.d.
Low Risk M 6 SD p.d. F 4 SD p.d.
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Risky Drinking Patterns
Percentage of the population who drink at medium
to high risk levels for acute harm at least once
a month (2001)
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Drinking Patterns for Chronic Harm
ABSTAINERS
High Risk M gt7 SD p.d. F gt5 SD p.d.
HIGH RISK
Risky M 5 - 6 SD p.d. F 3 - 4 SD p.d.
RISKY
LOW RISK
Low Risk M 4 SD p.d. F 2 SD p.d.
1 Standard Drink (SD) 10g of alcohol
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Indigenous Drinking Patterns

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Alcohol Induced Memory Loss

• Teenagers (28.4) were most likely to have memory
  loss incident following drinking
• 4.4 reported blackouts occurred on weekly
  basis
• 10.9 reported blackouts on a monthly basis
• Memory loss occurred after drinking for
• 12 male drinkers aged gt40 years
• 7 female drinkers aged gt40 years
• 20-30 of all other age groups.

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Alcohol andDays of Work or Study Missed
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NDRI (2000)
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Predisposing Factors for High Risk Drinking

• Family history of alcohol problems
• Childhood problem behaviours related to impulse
  control
• Poor coping responses in the face of stressful
  life events
• Depression, divorce or separation
• Drinking partner
• Working in a male dominated environment.

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Young People and Alcohol

• Risky and harmful levels may
• interfere with normal development
• - physiological
• - social
• - emotional
• increase risk of
• - suicide
• - risky sexual behaviour/ unwanted sex
• cause blackouts
• contribute to poor academic performance
• contribute to, or cause, mental health problems
• cause behavioural problems.

• Risk of alcohol-related harm increased due to
• smaller physical size
• fewer social controls
• peer values that condone intoxicated behaviour
• risk of overdose due to lack of tolerance
  (physical, behavioural).

NHMRC (2001)
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People With Concurrent Mental Health Problems

• Alcohol may
• exacerbate existing mental health problems
• interact with prescribed medications
• reduce or exacerbate the effect of certain
  medications
• reduce patient compliance with treatment regimes.

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Women and Alcohol

• Women are more susceptible to the effects of
  alcohol due to
• smaller physical size
• decreased blood volume
• lower body water fat ratio
• reduced ADH activity in gastric mucosa (hence
  reduced stomach metabolism of alcohol).
• Resulting in
• earlier development of organ damage
• increased risk of intoxication related harms
  e.g. assault, injury.

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Foetal Alcohol Syndrome

• The increasing prevalence
• of risky drinking by young
• women has raised concerns
• about foetal alcohol
• syndrome / effects.
• GPs are well placed to give
• sound preventive advice.

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Alcohol Effects on Brain

• No single receptor - interacts with and alters
  function of many different cellular components
• Primary targets are GABA, NMDA glutamate,
  serotonin and ATP receptors
• Stimulates dopamine and opioid systems
• Effects of chronic consumption are opposite to
  acute because of homeostatic compensation.

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Alcohol and the Opioid System

• Alcohol consumption ? production and release of
  opioid peptides
• mediate euphoric and rewarding effects of alcohol
  by ? dopamine release in the mid brain
• Opioid antagonists (e.g. naltrexone)
• blunt the euphoria-inducing effects of alcohol
• suppress priming effect of alcohol, limit amount
  consumed and peak BAC reached
• Individuals with family history of alcohol
  dependence have an ? rise in ? endorphin with
  alcohol.

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Pharmacokinetics
2 excreted unchanged in sweat, breath urine

• Rapidly absorbed into blood by stomach (20)
  and small intestine (80)

• Distributed in body fluids (not fat)

• 1 standard drink per hour raises BAC by approx.
  0.010.03 g.

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Effects of Alcohol Intoxication
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Types of Problems

• Different patterns of drug use result in
  different types of problems.
• Drug use may affect all areas of a patients life
  and problems are not restricted to dependent drug
  use.

Regular/excessive Use health finances relationship
s child neglect
Intoxication accidents / injury poisoning /
hangovers absenteeism high risk behaviour
Dependence impaired control drug-centred
behaviour anxiety / isolation / social
problems withdrawal
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Types of Problems

• Different patterns of drug use result in
  different types of problems.
• Drug use may affect all areas of a patients life
  and problems are not restricted to dependent drug
  use.

Regular/excessive Use health finances relationship
s child neglect
Intoxication accidents/injury poisoning/hangovers
absenteeism high-risk behaviour
Dependence impaired control drug-centred
behaviour anxiety/isolation/social
problems withdrawal
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How can Thorleys Model of Alcohol-related Harm
be Applied to the Following?

• A man sitting on a beach who
• is alone, drinking a single can of beer, goes for
  a swim, and leaves in his car
• is alone, having completed a 6-pack over a few
  hours, decides to go for a swim before driving
  home
• in the company of his children, consumes a 6-pack
  over a few hours, and takes them swimming before
  driving them home
• goes to the beach everyday, along with his dog
  and his esky, and consumes one or two 6-packs
  during the afternoon before driving home.

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Types of Problems
Intoxication

• Regular Use

• Vein damage
• InfectionsOrgan Disease
• Relationships
• Financial

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Types of Problems
Intoxication

• Dependence

Regular Use

• Withdrawal
• Craving
• Obsessive
• Cognitive Conflict
• Loss of Control

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Types of Problems Youth
Intoxication
Dependence
Regular Use
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Types of Problems Elderly
Intox.
Dep.
Regular Use
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Types of ProblemsClinical Samples
Intox.
Dependence
Regular Use
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Binge Drinking

• Binge drinking can lead to
• increased risk taking
• poor judgment/decision making
• misadventure/accidents
• increased risky sexual behaviour
• increased violence
• suicide.

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Harms Associated with High Risk Alcohol Use

• Hypertension, CVA
• Cardiomyopathy
• Peripheral neuropathy
• Impotence
• Cirrhosis and hepatic or bowel carcinomas
• Cancer of lips, mouth, throat and oesophagus
• Cancer of breast
• Foetal alcohol syndrome.

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Harms Associated with High-risk Alcohol Use

• Hypertension, CVA
• Cardiomyopathy
• Peripheral neuropathy
• Impotence
• Cirrhosis and hepatic or bowel carcinomas
• Cancer of lips, mouth, throat and oesophagus
• Cancer of breast
• Foetal alcohol syndrome.

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Alcohol-related Brain Injury

• Cognitive impairment may result from consumption
  levels of gt70 grams per day
• Thiamine deficiency leads to
• Wernickes encephalopathy
• Korsakoffs psychosis
• Frontal lobe syndrome
• Cerebellar degeneration
• Trauma.

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Alcohol
Courtesy of Dr. John Sherman, St. Kilda Medical
Centre
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Alcohol
Courtesy of Dr. John Sherman, St. Kilda Medical
Centre
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Alcohol
Courtesy of Dr. John Sherman, St. Kilda Medical
Centre
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Alcohol Dependence
It has been estimated that alcohol dependence is
more common than dependence on all other drugs
combined in the Australian adult population, and
over 17 times as common as opioid dependence.
Hall et al. (1998)
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Case Study

• Meg, a 47 year old woman, always has alcohol on
  her breath and frequently falls. She moved into
  the suburb a few months ago and is well known at
  the local bottle shop and hotel. She denied
  alcohol use until a recent fracture and hospital
  admission. Since her discharge she has started
  drinking again, mostly spirits.
• She presents to you late one afternoon seeking
  benzodiazepines.
• As her new GP, how will you respond?
• If her alcohol use continues, how can harm be
  reduced?

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Drug Alcohol Interactions

• CNS depressants
• e.g. benzodiazepines
• Antipsychotics, antidepressants
• Opioid analgesics, antihistamines (some)
• Hypoglycaemics (chlorpropamide), metronidazole,
  cephalosporins (some)

• Confusion, depressed respiration
• Decreased metabolism, toxicity CNS depression
• CNS depression
• Facial flushing, headache

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Alcohol-related Problems in General Practice

• Most drinkers in general practice tend to be
• non-dependent (binge) drinkers who may experience
  intoxication-related harm
• people who regularly drink at risky levels
• responsive to brief intervention strategies e.g.
  self-help materials.

Although GPs should be encouraged to
intervene with all problem drinkers, alcohol
dependent drinkers may require additional
specialist assistance.
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Interventions and Treatment for Alcohol-related
Problems

• Screening and Assessment ? individualised
  interventions
• Brief intervention and Harm Reduction strategies
• Withdrawal management
• Relapse prevention / goal setting strategies
• Controlled drinking programs
• Residential programs
• Self-help groups.

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Screening Tools
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Brief Intervention

• Consider the patients
• perspective on drinking
• attitudes to drinking goals
• significant others
• short-term objectives.
• Provide
• information on standard drinks, risks, and risk
  levels
• encouragement to identify positive alternatives
  to drinking
• self-help manuals
• follow-up session.

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Two Steps Towards Alcohol Brief Intervention (BI)

• 1. Screening
• E.g. the alcohol AUDIT, a 10-item questionnaire.
• 2. Intervention
• Information
• Brief counselling
• Advice
• Referral (if required).

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What Does AUDIT Measure?
The items measure

• Questions 13 Quantity and frequency of alcohol
  use
• Questions 46 Possible dependence on alcohol
• Questions 710 Alcohol-related problems
• AUDIT Scores Risky levels 812
• Possible dependence gt13

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Suitability of AUDIT as a BI Tool

• SUITABLE FOR
• anyone over 16 years
• routine assessment of all new patients
• hospital admissions
• pre-operative assessment,employment medicals
  etc.

• LESS WELL SUITED
• if physically or psychologically unwell, or have
  cognitive impairment
• in Emergency Departments
• for palliative care
• if alcohol-related damage present
• with poor literacy skills
• if withdrawal/dependence evident.

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AUDIT The FLAGS Approach

• After administering the AUDIT use FLAGS.
• Feedback results
• Listen to patient concerns
• Provide Alcohol education and information
• Goals of treatment identify and plan
• Strategies discussed and implemented.

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Using FRAMES for Brief Interventions (BI)

• Feedback personal risk or impairment
• Emphasise personal Responsibility for change
• Provide clear Advice on how to change
• Offer a Menu of alternative change options
• Use therapeutic Empathy as a counselling style
• Enhance client Self-efficacy or optimism.

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Harm Reduction Strategies

• Benefits of cutting down or cutting out
• save money
• be less depressed
• lose weight
• less hassles for family
• have more energy
• sleep better
• better physical shape.

• Reduce the risk of
• liver disease
• cancer
• brain damage
• high blood pressure
• accidents
• injury
• legal problems.

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Choosing a Treatment Option
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Withdrawal

• Usually occurs 624 hours after last drink
• tremor
• anxiety and agitation
• sweating
• nausea and vomiting
• headache
• sensory disturbances hallucinations.

• Severity depends on
• pattern, quantity and duration of use
• previous withdrawal history
• patient expectations
• physical and psychological wellbeing of the
  patient (illness or injury)
• other drug use/dependence
• the setting in which withdrawal takes place.

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Progress of Alcohol Withdrawal from Time of Last
Drink
deCrespigny Cusack (2003) Adapted from NSW
Health Detoxification Clinical Practice
Guidelines (20002003)
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Home-based Withdrawal Management

• Is suitable when
• the GP is able, available and willing!
• carer support is available
• patient has organised responsibilities and
  commitments (e.g. work)
• patients physical and emotional condition is
  appropriate.

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Home-based Withdrawal
Medications for Symptomatic Treatment

• Diazepam
• Thiamine ?100 mg daily multivitamins
• Antiemetic
• Analgesia (e.g. paracetamol)
• Antidiarrhoeal.

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Post-withdrawal Management

• GP options
• retain in treatment, ongoing management
• seek referral.
• Considerations
• patients wants (abstinence or reduced
  consumption, remaining your patient)
• severity of problems.
• Pharmacotherapies
• acamprosate
• naltrexone
• disulfiram (not PBS listed).

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Acamprosate

• Derivative of the amino-acid taurine (calcium
  bis acetyl homotaurine)
• Complex pharmacological actions
• Interacts with the GABAA receptor, facilitating
  inhibitory neurotransmission
• ? glutamate excitatory neurotransmission
  interacts with NMDA glutamate receptor.

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Naltrexone and Acamprosate

• Effective
• Work well with variety of supportive treatments
  e.g. brief intervention, CBT, supportive group
  therapy
• Start following alcohol withdrawal proven
  efficacy where goal is abstinence, uncertain with
  goal of moderation
• No contraindication while person is still
  drinking, although efficacy uncertain
• Generally safe and well tolerated.

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Clinical Guidelines

• Naltrexone 50 mg daily
• indicated especially where strong craving for
  alcohol after a priming dose
• ? likelihood of lapse progressing to relapse
• LFTs lt x3 above normal
• side effects nausea headache.

• Acamprosate 600 mg (2 tabs) tds
• indicated especially where susceptible to
  drinking cues or drinking triggered by withdrawal
  symptoms
• low potential for drug interactions
• need normal renal function
• side effects diarrhoea, headache, nausea, itch.

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Disulfiram

• Acetaldehyde dehydrogenase inhibitor 200 mg
  daily
• ? unpleasant reaction with alcohol ingestion
• Indications alcohol dependence goal of
  abstinence need for external aid to abstinence
• Controlled trials ? abstinence rate in first 36
  months
• Best results with supervised ingestion
  contingency management strategies.

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SSRIs

• ? alcohol consumption by 20 (low dependence
  drinkers), effect wears off after 12 months
• No increase in abstinence rates in alcohol
  dependence
• No change in overall alcohol intake in alcohol
  dependence
• Reserved for patients with persistent depression
  after withdrawal completed.

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