AlcoholRelated Problems

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Alcohol-Related Problems

• Dr Chris Madden
• GP VTS SHO

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(No Transcript)
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Alcohol

• Alcohol is part of our society
• gt80 population of England drink
• Has positive effects in moderation and to
  majority of population
• Health cardiovascular
• Socially
• But minority use alcohol harmfully high cost to
  the country

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Relevance To General Practice

• GPs ideally placed to identify alcohol misuse and
  dealing with it in various ways
• Preventing problematic drinking
• Recognising treating problematic drinkers
• Important job for the government

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Overview Alcohol-Related Problems

• How big is the problem? What are the costs to the
  country?
• Patterns of drinking in UK
• What role do General Practitioners play
• Recognising problems
• Treating problems

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How Big Is The Problem The Costs
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Alcohol The Costs

• According to government research
• Alcohol-related harm is costing around 20bn per
  year
• Strain on NHS is very large (1.7 billion) and
  can be reduced

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Alcohol The Costs

• Health harms
• Crime Anti-social behaviour
• Loss of productivity and profitability
• Harms to family and society

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The Health Costs

• Estimated 1.7 billion
• Expenditure of 95 million on specialist alcohol
  treatment
• Over 30,000 hospital admissions for alcohol
  dependence syndrome
• Up to 22,000 premature deaths per annum

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The Health Costs

• Up to 70 presentations to AE at peak times (fri
  and sat night)
• Up to 1,000 suicides
• Extra costs of worsened depression and anxiety in
  people who continue to drink

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The Antisocial Crime Costs

• Estimated cost 7.3 billion
• 1.2million violent crimes (half of all)
• 360,000 incidents of domestic violence (one third
  of all)
• Increased anti-social behaviour and fear of crime
  61 of population perceive alcohol-related
  violence as worsening
• Extra policing costs every major town across UK
  each Saturday night!

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The Productivity Profitability Costs

• Estimated 6.4 billion per annum
• Up to 17 million working days lost through
  alcohol-related absence
• Affects effectiveness of workers
• Shorter working lives

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The Family Society Costs

• Emotional impact suffered estimated at 4.7
  million due to alcohol and associated crimes
• Between 780,000 and 1.3 million children affected
  by parental alcohol problems
• Increased divorce marriages with alcohol
  problems are twice as likely to end in divorce

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Alcohol-drinking Patterns

• Chronic Drinkers
• Likely to be gt30 years old, 2/3 male
• Increased risk of cirrhosis, haemorrhagic stroke,
  cancer, suicide and premature death
• Increased contact with criminal justice system
  with domestic violence and drink driving
• Compounds multiple needs as often by vulnerable
  adults (MH pts, ex-prisoners, homeless, drug
  users etc)

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Alcohol-drinking Patterns

• Binge drinkers
• Likely to be lt25 years old, male (but female
  rising)
• Increased risk of accidents and alcohol poisoning
• Victims of/commit violent offences
• High level of AE attendance

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Recommendations Sensible Drinking

• 1992 Health Of The Nation White Paper
• Unit
• Male max 21 units per week
• Female max 14 units per week

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What is a Unit of Alcohol?

• A pint of ordinary strength lager, bitter cider
  - 2 units
• A pint of strong lager, best bitter or strong
  cider - 3 units
• A 175ml glass of red or white wine - 2 units
• A pub measure of spirits - 1 unit
• An alcopop - 1.5 units

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How the Population Drinks
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How The Population Drinks

• This does not take into account binge drinkers
  15 population
• Many of these people usually fit into recommended
  alcohol weekly intake but is in one night
• Binge drinking is unhealthy as well

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Recommendations Sensible Drinking

• 1995 revision (acknowledging binges)
• Male max 3-4 units per day, female 2-3 units per
  day
• 2 day alcohol-free days after heavy drinking
• Continued intake at upper limit dangerous
• Intake up to 2 units can be protective on heart
• Risky groups (pregnant, machine workers) little
  or none

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Alcohol Consumption Litres Pure Alcohol Per
Inhabitant 1999
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Alcohol Consumption in UK 1900-2000 per capita
consumption of 100 alcohol
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The Real Situation

• UK alcohol consumption continues to rise, static
  or decreasing in wine-producing countries
• Rising culture of binge drinking regarding
  getting drunk as a goodnight out
• More disposable income
• UK gradually rising from mid table to near top of
  world alcohol consumers

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The Real Situation

• Around 6 million people in England drank more
  than twice above the daily guidelines in the past
  week (binge drinkers)
• Around 8 million people drank more than former
  weekly guidelines (chronic drinkers)
• Around 2 million drink over 50 units per week
• Problem big and we will be treating them!

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Cabinet Office Document Alcohol Harm Reduction
Strategy March 2004

• Government acknowledging high costs of alcohol to
  country
• Recommends strategies to tackle problem

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Government Strategy To Tackle Alcohol Misuse

• Change behaviour culture targeted education
  communication
• Better identification of those with alcohol
  problems
• Improving treatment rehabilitation
• Prevent tackle alcohol-related crime disorder
• Work with alcoholic drinks industry to reduce
  harm

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How can GPs help the Government?

• Can help with 1-3
• Change behaviour targeted education
• Better identification
• Better treatment

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Targeted Education

• Primary Prevention Prevention of disease in
  susceptible individuals through promotion of
  health. Important GP job
• Public Health Government campaigns
• Posters in waiting rooms
• Leaflets to give to patients deemed to be at risk
• Opportunistic with every patient ask about and
  advise on safe drinking

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Targeted Education

• Other Government strategies
• Information provided by alcohol industry
• Education in schools (young are at risk)
• Education in workplace
• Advertising campaigns

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Identification of Problem Drinkers
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Presentations of Problem Drinkers to a GP

• Physical
• Psychological
• Social

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Physical Presentations

• Incidental findings of typical signs symptoms
  of history examination
• Accidents/injuries
• Violence/injuries
• Obesity and related sequelae
• Dyspepsia

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Physical Presentations

• Erectile dysfunction
• Seizures - ? Withdrawal
• Foetal alcohol syndrome dysmorphic LD
• Liver damage
• Anaemia
• Neurological cerebella or peripheral neuropathy

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Psychological Presentations

• Anxiety
• Depression
• Suicidality

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Social Presentations

• Loss of employment
• Disorderly conduct
• Domestic violence (victims)
• Relationship problems/breakdown
• Drink driving offences

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Other Presentations

• AE
• Inpatient/outpatients, e.g. gastro/liver, maxfax,
  orthopaedics
• Mental Health services
• Antenatal care

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Other Presentations

• Social services
• Voluntary services
• Police Criminal Justice System
• Schools and Educational institutions

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Screening Problem Drinking

• Targeted screening more effective than a
  universal approach
• Screening tools
• Alcohol Use Disorders Identification Test (AUDIT)
  developed by WHO. Lengthy
• FAST Questionnaire is abbreviated AUDIT
• CAGE less effective in comparison to above no
  quantity assessment
• TWEAK T-AGE for antenatal/preconception
• May not need formal tool as general consultation
  questions by GP may suffice

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Treatment Of Alcohol Problems The Options
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Treatment Of Alcohol Problems The Options

• Depends on severity of alcohol problem vary
  from simple counselling to inpatient
  detoxification

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Treatment Of Alcohol Problems The Options

• Mild
• Brief Intervention by GP
• Motivational Interviewing (trained staff)
• Referral to lay services (alcoholics anonymous)

• Moderate-Severe
• Referral to specialist services
• Detoxification
• Adjuvant drugs (e.g. acamprosate)
• Inpatient vs community services
• Aftercare rehab with therapy for relapse
  prevention

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Treatment Of Alcohol Problems The Primary Care
Approach

• Mainly patient-facilitated less efficacy
  compliance if patient coerced
• Judge patient suitably how bad is the problem
  what level of treatment required?
• If patient referred on still review patient
  regularly
• Maintain long term contact once patient
  discharged from specialist care may relapse

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Specialist Services

• Local services vary
• Community drug and alcohol service, e.g. RESPOND
• Inpatient services
• Offer all kinds of services
• Counselling
• Detoxification as well as gateway to inpatient
  services
• Aftercare CBT, group and family therapy for
  relapse prevention

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Brief Interventions

• Evidence shows effective approach for people
  whose drinking not yet severe
• Reduce alcohol consumption as a result
• Heavy drinkers 2x more likely to cut down
• Given by GP/nurse, no specific training
• Can be regarded as opportunistic and still in
  realm of primary prevention

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Brief Interventions

• No standard definition
• Short conversation
• Giving information advice
• Encouraging person to consider ve and ve
  aspects of drinking behaviour
• Information on specialist and lay services
• May refer on if patient requests

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Motivational Interviewing

• By trained member of staff GP or referred to
  local alcohol specialist services
• Portray empathy
• Developing discrepancy enhance awareness of
  consequences balancing pros cons of alcohol
• Avoiding argument
• Supporting self-efficacy
• Facilitating reinforcing self-motivating
  statements

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Assisting Withdrawal From Alcohol Deciding on
Detoxification
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Medical Detoxification

• Usually in home over 3-7 days
• With support of GP, nurse or alcohol treatment
  worker
• Advise of side effects of withdrawal
• Advise patient to totally avoid alcohol
• Advise patient to avoid stress
• Monitor withdrawal symptoms breath alcohol
• Use chlordiazepoxide as reducing dose

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Medical Detoxification
Each unit denoting 10mg chlordiazepoxide
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Other Management Issues Thiamine

• Signs of Wernickes-Korsakoffs Syndrome
  admitted for inpatient pabrinex (need resus
  facilities)
• Community detox consider 3 day im pabrinex if
  any features of risk for above
• Chronic alcohol problem oral thiamine
  indefinitely

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Other Management Issues Delirium
Tremens/Severe Withdrawal

• At major risk of seizure, coma death
• Emergency admission for chlordiazepoxide

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Summary

• Problematic alcohol consumption is very costly to
  the economy
• Problem drinking in UK becoming worse
  particularly binge drinking culture
• GPs can help by effective prevention,
  identification and treatment of cases
• Treatment has to be tailored to the severity of
  the case

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References

• RCGP Curriculum statement 15.3,
  http//www.rcgp.org.uk/education/education_home/cu
  rriculum/gp_curriculum_documents.aspx
• Cabinet Office Document Alcohol Harm Reduction
  Strategy March 2004,
• www. Strategy.gov.uk/work areas/alcoholmisuse/inde
  x.asp
• Scottish Intercollegiate Guidelines Network,
  www.sign.ac.uk

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Questions