rcgp smah 10 minute approach to alcohol practice based learning session

RCGP SMAH

10 minute approach to alcohol

Practice based learning session

Aims

Identify alcohol related problems and make a treatment plan in a primary care setting

Overview of the session

14.00

What does alcohol mean to you?

14.15

How to diagnose alcohol problems

14.45

Learning trios

15.30

Coffee Break

15.45

Medical Aspects

16.45

Finish and Evaluation

What does alcohol mean to you?

• Have you had any experiences with patients who drink?

• Do you drink?

• How does drinking affect you?

How to diagnose alcohol problems

Screening tools

Calculating alcohol units

Brief Intervention

…is a method of identifying alcohol consumption at a level sufficiently high to cause concern.

Alcohol Screening…

Screening tools in primary care

AUDIT alcohol use disorder identification test

FAST fast alcohol screening test

AUDIT-C AUDIT alcohol consumption questions

AUDIT-PC AUDIT primary care

M-SASQ modified single alcohol screening question

Coulton S, Drummond DC, James D, Godfrey C, Bland JM, Parrott S, Peters T: Opportunistic screening for alcohol use disorders in primary care: comparative study. British Medical Journal 2006 , 332:511-7.NICE public health guidance 24: Alcohol-use disorders: preventing harmful drinking, Evidence statement e5.1

AUDIT

• Developed by the WHO specifically for use in primary care, validated in more than 22 countries

• gold standard in screening tools• Sensitivity 92% and specificity 94% to identify

increased, higher risk and possible dependent drinking

Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO Collaborative Project on Early Detection of Persons with Harmful Alcohol Consumption. Saunders JB, Aasland OG, Babor TF, de la Fuente JR, Grant M. Addiction. 1993 Jun;88(6):791-804.

ScoreDH

TerminologyNICE/WHO

Terminology

0 - 7 Lower Risk

8 - 15 Increasing RiskHazardous Drinking

16 - 19

Higher Risk Harmful Drinking

20 - 40

Possible Dependence

AUDIT scores

AUDIT Score

NICE/WHO Terminology

0 - 7 Lower Risk Within recommended limits

8 - 15 HazardousAbove recommended limits

no significant harm

16 - 19 HarmfulAbove recommended limits

AND significant harm

Clinical definitions

Typology (general population)

DoH 2005

Severely dependent drinkers (< 0.1%)

Moderately dependent drinkers (< 0.4%)

Harmful drinkers (4.1%)

Hazardous drinkers (16.3%)

Low-risk drinkers (67.1%)

Non-drinkers (12.0%)

Physical health risks

Condition Men Women

Hypertension

4x 2x

Stroke 2x 4x

CHD 1.7x 1.3x

Pancreatitis 3x 2x

Liver disease

13x 13x

Source: Safe. Sensible. Social: the next steps in the national alcohol strategy (HM Government, 2007)

What is Brief Intervention?

• can be anything from a short conversation to a number of sessions

Brief interventions help the patient to understand:

•What consequences likely to be

•What they can do about it

•What help is available

Who is Brief Intervention for?

AUDIT Definition Intervention

0 - 7 Lower risk Positive reinforcement

8 - 15 Hazardous Brief Intervention

16 - 19

Harmful Extended Brief Intervention

20 - 40 Possible dependence

Further Assessment

• Brief intervention is for hazardous and harmful drinking

• Usefulness is limited for dependent drinking

Brief Interventions

Brief Intervention Extended Brief Intervention

Increasing Risk Higher Risk

single consultation multiple consultations

Brief structured advise

Up to 45 minutes structured intervention

Goal setting Goal setting over time

Consider further examination

Physical examination and investigations

Limited follow-up Structured follow up

Structure of Brief Interventions

FRAMES

Feedback (personalised)

Responsibility (with patient)

Advice (clear, practical)

Menu (variety of options)

Empathy (warm, reflective)

Self-efficacy (boosts confidence)

Bien, T. H., Miller, W. R. and Tonigan, J. (1993) Brief interventions for alcohol problems: a review. Addiction 88, 315–336.

Does brief intervention work?

1 in 8

individuals drinking at hazardous or harmful levels act on their doctors advice and

moderate their drinking to low risk levels.

This compares to 1 in 20 individuals offered smoking advice (1 in 10 when nicotine

replacements are offered).

Alcohol: No Ordinary Commodity - Research and Public Policy (Babor et al 2003)

Does more intervention help more?

Brief Intervention:• is often as effective as more extensive

treatments• should not substitute for specialist treatment• Might serve as an initial treatment for

severely dependent

Bien, T, Miller, W.R. and Tonigan, J.S.Brief interventions for alcohol problems: A review. Addiction 88: 315-336, 1993.

Moyer, A., Finney, J., Swearingen, C. and Vergun, P. Brief interventions for alcohol problems: A meta-analytic review of controlled investigations in treatment-seeking and non-treatment seeking populations. Addiction 2002 Mar;97(3):279-92.

Calculating units of alcohol

Litres x ABV = Units

Examples: 1 Litre of 4% lager = 4 units

0.75 Litres of 12% wine = 9 units

Adults visiting GP

Requesting help with alcohol problem

New Registration Other health complaint

Full ScreenAUDIT

AUDIT Score8-15

Full Assessment

Referral to Specialist Services

ExtendedBrief Advice

AUDIT Score16-20

AUDIT Score20+

AUDIT Score 0-7

No action

PositiveResult

NegativeResult

FAST AUDIT - CInitial Screening Tools

Brief Advice

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© Department of Health 2008

Question time

Learning trios

• In groups of 3 you will take turns to be the GP/practitioner, patient and observer in role play – each person will have a go at being all three

• The patient and the GP will each play the character identified in the case given to them on the card       

• The GP will deliver the AUDIT and undertake alcohol unit calculation

• The GP’s role is to respond and deliver a “brief intervention” to the patient if appropriate

• The Observer’s role is to note what helps and hinders the interactions between GP and Patient and then feedback to the GP and Patient in the five remaining minutes before swapping roles

• The exercise is completed when all members have had an opportunity to play GP, patient and observer

Brief intervention exercise

• Include an AUDIT assessment• Decide what level of intervention is

appropriate for your case• Conduct a brief intervention if appropriate

Learning trios

Feedback

How did you feel that went?

Any difficulties?

Any anticipated problems?

Learning trios

Tea break

15.45 Medical Aspects of alcohol

misuse

Next session

Medical Aspects

Investigations

Detoxification

Medication

Risks

Case Scenario

A 36 year old man attends your surgery on a Friday afternoon. Mildly intoxicated.

PC: He says that he is dependent on alcohol and will go into withdrawal soon as he ran out of money to buy alcohol. He requests an alcohol detoxification.

O/E: Overall well, no signs of malnourishment.

No signs of alcohol withdrawal

Case Scenario

A 46 year old woman attends your surgery.

PC Feeling unwell in the morning, vomiting at times

increasing memory problems

O/E Looks malnourished, without any specific findings. BP 155/90, pulse 90. Liver slightly enlarged.

As you have no idea what is going on, you request a blood test: FBC, U&E, LFTs, TFTs. All come back as normal apart from the LFTs, which are slightly raised (<2x normal).

Case scenario

A 25 year old man attends your surgery. He is drunk to a degree that he could not find your consultation room initially.

He requests a sick note as he is an alcoholic.

Investigations

Dependency makes physical harm caused by alcohol more likely

but

a substantial amount of harmful drinking patients will develop medical problems

Like in coronary heart disease, a low risk score does not guarantee safety.

Investigations

• Simple questionnaire-based screening tools are more effective to identify problematic drinking

• FBC (anaemia and raised MCV)

• LFT (consider GGT)

Abnormal blood tests – what now?

NICE recommends:

• Abnormal LFTs – exclude alternative causes of liver disease

• Refer to a specialist to confirm a clinical diagnosis of alcohol-related liver disease.

National Institute of Clinical Excellence: CG100 Alcohol-use disorders: physical complications. Published May 2010

GGT

• only elevated in 30% heavy drinkers • up to 50% of all raised GGT is due for other

reasons• less likely to be elevated in young people,

episodic drinkers, women• A possible tool in monitoring

Physical signs of alcohol misuse

• Peripheral neuropathy

• Signs of chronic liver disease

• Neurological symptoms

• Proximal myopathy

• Cardiomyopathy

• Enteropathy

• Signs of withdrawal

Why assess dependence?

… because it is dangerous not to!

• Sudden stop of drinking may result in developing serious and life threatening conditions such as withdrawal fits, delirium tremens and Wernicke’s encephalopathy.

• Non-dependent drinkers can usually cut down and reduce associated problems

• Dependent drinkers (by definition) find reducing more difficult.

• Dependent drinkers generally need assistance to stop drinking

Dependent vs harmful drinkers

• AUDIT > 16 requires further assessment• AUDIT score of >35 or >50U per day makes

dependence likely• Need for medically assisted withdrawal and

assessment of co-morbidity • SADQ

Quantifying dependency

AUDIT SADQSleep

durationEye

openerWith-

drawalUnits/day

Harmful 16+ <3 normal - - <15

Dependence

Mild 16+ <15 8+ hrs - + <15

Moderate 20+ 15-30 6-8 hrs + ++ 15-30

Severe 20+ 30+ 4-6 hrs ++ +++ 30+

• SADQ – establish severity of dependency• 20 item questionnaire• Score correlates with expected severity of withdrawal

ScoreSeverity of dependency

0-3 No dependency

4-19 Mild

20-30 Moderate

31+ Severe

Stockwell, T., Sitharan, T., McGrath, D.& Lang, . (1994). The measurement of alcohol dependence and impaired control in community samples. Addiction, 89, 167-174.

Who needs detoxification? Use SADQ!

A sobering thought…..

• Detoxification is but one event in a continuing process

• It is a technical step between preparation and aftercare

• As a stand alone treatment can do more harm than good

• Detoxification from opiates and alcohol are two very different events

• Detoxification from opiates is uncomfortable, but fairly safe, whilst detoxification from alcohol is potentially dangerous, and can be permanently disabling or fatal

Who doesn’t need detoxification?

• Generally <15 units/day (M) or 10 units/day (F)• No recent withdrawal symptoms• No drinking to prevent withdrawal• Occasional binges lasting <1 week• SADQ (Severity of Alcohol Dependence

Questionnaire) < 4

Where can detoxifications take place?

• General Hospital• Psychiatric Hospital• Non statutory rehab or detoxification unit• Community

Community detoxification shows similar outcomes to inpatient – 75% successful in community

Community setting preferred by most patients Accessibility and trust in practitioner is key advantage Cost advantage

Stockwell T, Bolt L, Milner I, Russell G, Bolderston H, Pugh P (1991). Home detoxification from alcohol; its safety and efficacy in comparison with inpatient care. Alcohol and Alcoholism;26(5-6):645-650.

Finney J, Hahn A, Moos R (1995). The effectiveness of inpatient and outpatient treatment for alcohol abuse: the need to focus on mediators and moderators of setting effect. Addiction;91(12):1773-1796

Alcohol Withdrawal Syndrome (AWS)

• Autonomic over-activity and hyperactivity• Anxiety and tremor• Nausea and vomiting• Sweating• Tachycardia• Hypertension• Pyrexia

Progression of AWS

Complications of AWS

• Withdrawal seizures

• Delirium Tremens

• Wernicke’s encephalopathy and alcohol confusional withdrawal syndromes

• Severe depression/suicide

• Cardiovascular catastrophe (CVA, MI)

Beware the older patient…

NICE guidelines on Detoxification

Acute alcohol withdrawal

For people in acute alcohol withdrawal with, or who are assessed to be at high risk of developing, alcohol withdrawal seizures or delirium tremens, offer admission to hospital for medically assisted alcohol withdrawal.

National Institute of Clinical Excellence: CG100 Alcohol-use disorders: physical complications (CG100). Published May 2010

Medication

Harm reduction

Thiamine, Vit B Costrong

Detoxification

Chlordiazepoxide, Diazepam, Carbamazepine

Relapse prevention or controlled reduction

Naltrexone Nalmefene

Disulfiram (Antabuse®) Acamprosate

Thiamine

Offer prophylactic oral thiamine to harmful or dependent drinkers:

• if they are malnourished or at risk of malnourishment or

• if they have decompensated liver disease or

• if they are in acute withdrawal or

• before and during a planned medically assisted alcohol withdrawal.

National Institute of Clinical Excellence: CG100 Alcohol-use disorders: physical complications. Published May 2010

Community Detoxification

Chlordiazepoxide

Day Total daily dose

1 120mg

2 100mg

3 80mg

4 60mg

5 40mg

6 20mg

7 10mg

Examples of a community detoxification regime:Total daily dose should be given in three to four divided doses

Diazepam

Day Total daily dose

1 40mg

2 35mg

3 30mg

4 20mg

5 15mg

6 10mg

7 5mg

Naltrexone

• Recommended by NICE, but not licensed for controlled reduction

• 50mg tablet once daily• Opioid antagonist• Can be used together with Acamprosate or on its own

Nalmefene

Similar mechanism to Naltrexone

Licensed in the UK to support controlled reduction

PRN up to once daily

Acamprosate (Campral®)

• Well tolerated

• reduces craving after a detoxification and might help

with cutting down alcohol intake

• 333mg two tablets tds (reduced if < 60kg)

• CI: renal failure, decompensated cirrhosis

• patients should engaged in aftercare• Varies in effectiveness between patients

Disulfiram (Antabuse®)

• Evidence for efficacy only if supervised• Numerous contraindications • Severe aversive reaction after any alcohol:

flushing, palpitations, hypotension, vomiting, headache

• Should be initiated in consultation with specialist service

Case Scenario - review

A 36 year old man attends your surgery on a Friday afternoon. Mildly intoxicated.

PC: He says that he is dependent on alcohol and will go into withdrawal soon as he ran out of money to buy alcohol. He requests an alcohol detoxification.

O/E: Overall well, no signs of malnourishment.

No signs of alcohol withdrawal

Would you do anything different now?

Case Scenario

Would you do anything different now?

A 46 year old woman attends your surgery.

PC Feeling unwell in the morning, vomiting at times

increasing memory problems

O/E Looks malnourished, without any specific findings. BP 155/90, pulse 90. Liver slightly enlarged.

As you have no idea what is going on, you request a blood test: FBC, U&E, LFTs, TFTs. All come back as normal apart from the LFTs, which are slightly raised (<2x normal).

Case scenario

Would you do anything different now?

A 25 year old man attends your surgery. He is drunk to a degree that he could not find your consultation room initially.

He requests a sick note as he is an alcoholic.

Question time

Competencies

Understanding, awareness and knowledge

Categories of problem drinking

Screening tools,

calculate units of alcohol

Awareness of alcohol related health problems

Skill

Use AUDIT questionnaire

Deliver brief interventions

Where can I learn more?

RCGP Alcohol Certificate

Alcohol Learning Centre

Summary and feedback

Please leave feedback forms!

You can email any suggestions to:

carsten.h.grimm@gmail.com

RCGP SMAH

You’ve done it!

Finish