alcohol & alcohol related problems
TRANSCRIPT
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Dr. R.A.N.S. Rajapakshe
SHO Medicine
BH - Wathupitiwala
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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
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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
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One Unit = 8g of absolute Alcohol
Blood alcohol concentration = 15- 20 mg/dl
Amount metabolized in 1 hour duration
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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
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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.
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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
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Homicide / AttemptedSuicide / AttemptedOther intentional injuries (i.e., interpersonal
violence)Domestic violenceSexual assaultUnprotected sexMotor vehicle accidentsOther accidents
DrowningBurns
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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
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Lower workplace productivity
Unemployment
To family & social networks
Truancy & school exclusion
Homelessness
Economic costs
Child abuse
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CNS Epilepsy
Wernicke- Korsakoff syndrome
Polyneuropathy
CVS
Cardiomyopathy
Beriberi heart diseaseCardiac arrhythmias
Hypertension
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Respiratory system
Chest infections
GIT-
Acute gastritis
CA of oesophagus/ large bowelPancreatic disease
Liver disease
Musculoskeletal system Acute/ chronic myopathy
Osteoporosis
Osteomalacia
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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
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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
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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)
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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)
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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
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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
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Using the full AUDIT as the criterion, FAST shows a sensitivity of 91% & a specificity of95%.
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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%
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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)
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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
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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
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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
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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
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Most serious withdrawal state
After 1 3 days of alcohol cessation
Symptoms
disorientation
agitationmarked tremor
visual hallucinations
Signs
sweatingtachycardia
tachypnoea
pyrexia
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Complications
dehydration
infections
hepatic disease
Wernicke- Korsakoff syndrome
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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
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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
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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
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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
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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)
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Try to involve partner in treatment plan
Plan longer term help
individual/ group counselling
AA meetings
Help for the family
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Brief intervention
Motivational therapy through motivational
approach
Referral to lay services (Alcohol Anonymous)
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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
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Patients who do not respond to brief interventionmore intensive psychological intervention
based on five stages of change
PRECONTEMPLATION
CONTEMPLATION
DETERMINATION/PREPERATION
ACTION
MAINTENANCE
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In Pre-contemplation,
The person is unaware, unwilling, ortoo discouraged to change within
next six month.
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In Contemplation,
The person is thinking aboutchanging a behavior within next six
months.
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In Determination,
The person is seriously considering& planning to change a behavior
within 30 days & has taken stepstoward change.
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InAction,
The person is actively doing thingsto change or modify behavior.
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In Maintenance,
The person continues to maintainbehavioral change[for at least six
months] until it becomespermanent.
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In Relapse,
The person returns to pattern ofbehavior that he/she has begun tochange & thus returns to one of thefirst three stages.
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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
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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
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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
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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
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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