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Alcohol
“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 (1822–1895)
In the late 1800’s Dr William Osler described alcohol as:
“the 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 (1856–1950)
Alcohol
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.
Alcohol
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)
Rationale for GP Involvement
There is a strong case for GP involvement with patients’
drinking behaviour. It includes:
• 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.
Alcohol
Common Alcohol-related
GP Presentations
• Examples include:
– GI problems
(esp. Monday morning)
– high blood pressure
– sleep disorders
(esp. insomnia)
– injuries
– anxiety problems
– depression
– marital discord
– child abuse.
• 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 cost
effectiveness of treatment.
Alcohol
Alcohol
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.
Alcohol
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.
Alcohol
What Patients Think
Problem Areas
Doctor should
be interested
Doctor has shown
interest
1. Weight Control
83%
48%
2. Cigarette Smoking
80%
51%
3. Alcohol Use
79%
41%
4. Physical Fitness
72%
38%
adapted from Wallace & Haines (1984)
Alcohol
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.
Alcohol
Australia’s Drinking Guidelines
• Australia’s drinking
guidelines were
developed by the
NHMRC.
• See
www.nhmrc.gov.au
Alcohol
Who drinks?
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
73.6
90.1
87
86
82.8
72.5
Recent drinker
Ex-drinker
Never drank
4.8
21.6
14-19
12.8
7.6
9.6
4.5
5.4
7.1
5.9
6.4
7.6
20-29
30-39
40-49
50-59
14.7
60+
Age
Alcohol
A Standard Drink
Alcohol
Risky Drinking Levels
(for chronic harm)
Alcohol
High and Low Risk Drinking Levels For Short- and
Long-Term Harm
Risk of harm in the short-term
Risk of harm in the long-term
Low Risk
Risky
High Risk
(standard (standard (standard
drinks)
drinks)
drinks)
MALES
On an
occasional
day (NOT
every day)
FEMALES
On an
occasional
day (NOT
every day)
up to 6
7 to 10
11 or
more
Low Risk
Risky
High Risk
(standard (standard (standard
drinks)
drinks)
drinks)
MALES
On an
average
day
Overall
weekly
level
up to 4
5 to 6
7 or more
NHMRC Alcohol Guidelines (2001)
FEMALES
On an
average
day
Overall
weekly
level
up to 4
5 to 6
7 or more
up to 28
29 to 42
43 or
more
up to 2
3 to 4
5 or more
up to 14
15 to 28
29 or
more
Alcohol
Risky Drinking Patterns
• 34% of drinkers (>14 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 14–19, and over one in
six males aged 20–29, put themselves at risk of
alcohol-related harm, in the short term
• 60% of 20–29 year olds drink in a risky manner
• 12% do so at least weekly.
Alcohol
Drinking Patterns for Acute Harm
ABSTAINERS
18%
•
•
•
High
Risk
High
Risk
•
•
•
Risky
Risky
M:> 7 >7
M:
SD SD
p.d. p.d.
F:> 5 >5
F:
SD SD
p.d. p.d.
•
•
•
M:> 11>11
SD
M:
SD p.d.
p.d.
F:> 7 >7
F:
SD SD
p.d. p.d.
RISKY /
HIGH RISK
34%
LOW RISK
48%
Low Risk
M: 6 SD p.d.
M: 6 SD p.d.
F: 4 SD p.d.
Low Risk
F: 4 SD p.d.
Alcohol
Risky Drinking Patterns
Percentage of the population who drink at medium to high risk
levels for acute harm at least once a month (2001)
30
25
Males
Females
20
%15
10
5
0
14-19
20-29
30-39
Age
40-49
50-59
60+
Alcohol
Drinking Patterns for Chronic Harm
ABSTAINERS
High Risk
M: >7 SD p.d.
F: >5 SD p.d.
17%
HIGH RISK 3%
Risky
M: 5 - 6 SD p.d.
F: 3 - 4 SD p.d.
Low Risk
M: 4 SD p.d.
F: 2 SD p.d.
RISKY 7%
LOW RISK
73%
1 Standard Drink (SD)
= 10g of alcohol
Alcohol
Indigenous Drinking Patterns
70
60
50
%
40
Non-indigenous
Indigenous
30
20
10
0
occasional
regular
hazardous
Alcohol
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 >40 years
– 7% female drinkers aged >40 years
– 20-30% of all other age groups.
Alcohol
Alcohol and
Days of Work or Study Missed
13.2
14
12
10.4
10
8
7.2
6.9
men
women
6
3.7
4
2.7
2
2.1
0.3
0
14-19
20-29
30-39
40+
Age (yrs)
Alcohol
Overall age distribution among alcoholrelated serious road injuries occurring on
Australian roads (excluding Victoria),
1990–1997
23%
11%
0-14 yrs
15-24 yrs
25-34 yrs
35-44 yrs
6%
45-54 yrs
55+ yrs
5%
52%
3%
NDRI (2000)
Alcohol
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.
Alcohol
Young People and Alcohol
Risky and harmful levels may:
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)
•
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.
Alcohol
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.
Alcohol
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.
Alcohol
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.
Alcohol
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.
Alcohol
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.
Alcohol
Pharmacokinetics
5 minutes
to affect
brain
2% excreted
unchanged in
sweat, breath &
urine
• Rapidly absorbed into blood by
stomach (20%) and small intestine (80%)
• Metabolised by liver (95–99%)
alcohol
acetaldehyde
acetic acid & H2O
CO2
• Distributed in body fluids (not fat)
• 1 standard drink per hour raises
BAC by approx. 0.01–0.03 g%.
Alcohol
Effects of Alcohol Intoxication
.01-.02
Clearing of head
.02-.05
Mild throbbing rear of head, slightly dizzy, talkative,
euphoria, confidence, clumsy, flippant remarks
.06-1.0
 inhibitions,  talkativeness,  motor co-ord,
 pulse, stagger, loud singing!
0.2-0.3
Poor judgement, nausea, vomiting
0.3-0.4
Blackout, memory loss, emotionally labile
0.4+
Stupor, breathing reflex threatened, deep
anaesthesia, death
Alcohol
Types of Problems
Different patterns of drug use result in different types of problems.
Drug use may affect all areas of a patient’s life and problems are
not restricted to dependent drug use.
Intoxication
accidents / injury
poisoning / hangovers
absenteeism
high risk behaviour
I
R
D
Regular/excessive
Use
health
finances
relationships
child neglect
Dependence
impaired control
drug-centred behaviour
anxiety / isolation / social problems
withdrawal
Alcohol
How can Thorley’s 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.
Alcohol
Types of Problems
Intoxication
·
Regular Use
Vein damage
Infections
Organ Disease
Relationships
Financial
Alcohol
Types of Problems
Intoxication
Dependence
·
Regular Use
Withdrawal
Craving
Obsessive
Cognitive Conflict
Loss of Control
Alcohol
Types of Problems: Youth
Intoxication
Regular Use
Dependence
Alcohol
Types of Problems: Elderly
Intox.
Dep.
Regular
Use
Alcohol
Types of Problems:
Clinical Samples
Intox.
Dependence
Regular Use
Alcohol
Binge Drinking
Binge drinking can lead to:
– increased risk taking
– poor judgment/decision making
– misadventure/accidents
– increased risky sexual behaviour
– increased violence
– suicide.
Alcohol
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.
Alcohol
Alcohol-related Brain Injury
• Cognitive impairment may result from
consumption levels of >70 grams per day
• Thiamine deficiency leads to:
– Wernicke’s encephalopathy
– Korsakoff’s psychosis
• Frontal lobe syndrome
• Cerebellar degeneration
• Trauma.
Alcohol
Courtesy of Dr. John Sherman, St. Kilda Medical Centre
Alcohol
Courtesy of Dr. John Sherman, St. Kilda Medical Centre
Alcohol
Courtesy of Dr. John Sherman, St. Kilda Medical Centre
Alcohol
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)
Alcohol
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?
Alcohol
Drug + Alcohol Interactions
• CNS depressants
e.g. benzodiazepines
Confusion, depressed
respiration
• Antipsychotics,
antidepressants
Decreased metabolism,
toxicity & CNS depression
• Opioid analgesics,
antihistamines (some)
CNS depression
• Hypoglycaemics
(chlorpropamide),
metronidazole,
cephalosporins (some)
Facial flushing, headache
Alcohol
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.
Alcohol
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.
Alcohol
Screening Tools
Test/Tool
 Breathalyser
 Bloods/
 LFTs
 CAGE
Advantages
Disadvantages
 Immediate results
 Machine expensive
 Accurate
 Unable to assess for
problematic drinking
 Identifies recent drinking
 Help relate health problems to drinking  Specific only to liver disease,
patterns
 Short
 Can be used in interview or self-report
 No special tools required
 Identifies hazardous/harmful drinking
not patterns of drinking
 Less sensitive than clinical
judgement
 Insensitive to low-level
problematic drinking patterns
patterns
 AUDIT
 Focuses on recent use, identifies
patterns
 Can identify best intervention
 Accurate, cross-culturally validated
 For administration or self-report
 Require copy of tool and
interpretation information
Alcohol
Brief Intervention
Consider the patient’s:
• 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.
Alcohol
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).
Alcohol
What Does AUDIT Measure?
The items measure:
Questions 1–3
Quantity and frequency of alcohol use
Questions 4–6
Possible dependence on alcohol
Questions 7–10
Alcohol-related problems
AUDIT Scores: Risky levels
Possible dependence
8–12
>13
Alcohol
Suitability of AUDIT as a BI Tool
SUITABLE FOR:
LESS WELL SUITED:
• anyone over 16 years
• if physically or psychologically
unwell, or have cognitive
• routine assessment of all impairment
new patients
• in Emergency Departments
• hospital admissions
• for palliative care
• pre-operative
assessment,
• if alcohol-related damage present
employment medicals
• with poor literacy skills
etc.
• if withdrawal/dependence evident.
Alcohol
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.
Alcohol
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.
Alcohol
Harm Reduction Strategies
Benefits of cutting down
or cutting out:
Reduce the risk of:
• save money
• liver disease
• be less depressed
• cancer
• lose weight
• brain damage
• less hassles for family
• high blood pressure
• have more energy
• accidents
• sleep better
• injury
• better physical shape.
• legal problems.
Alcohol
Choosing a Treatment Option
Severity
Goal
No major
lifestyle
disruptions,
not severely
dependent
Reducing
consumption
/controlled
drinking
Major lifestyle Abstinence
disruptions,
significant
dependence
Treatment options
E.g.
•
•
•
•
•
outpatient counselling
group or individual work (skills
training, relapse prevention)
marital and family therapy
loss and grief counselling
self-help/support groups
Above options plus:
•
•
•
withdrawal management
pharmacotherapy
residential rehabilitation
Alcohol
Withdrawal
Usually occurs 6–24
hours after last drink:
Severity depends on:
• tremor
• pattern, quantity and duration
of use
• anxiety and agitation
• previous withdrawal history
• sweating
• patient expectations
• nausea and vomiting
• headache
• sensory disturbances –
hallucinations.
• physical and psychological
wellbeing of the patient
(illness or injury)
• other drug use/dependence
• the setting in which withdrawal
takes place.
Alcohol
Progress of Alcohol Withdrawal from
Time of Last Drink
deCrespigny & Cusack (2003)
Adapted from NSW Health Detoxification Clinical Practice Guidelines (2000–2003)
Alcohol
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)
• patient’s physical and emotional condition is
appropriate.
Alcohol
Home-based Withdrawal
Medications for Symptomatic Treatment
• Diazepam
• Thiamine 100 mg daily & multivitamins
• Antiemetic
• Analgesia (e.g. paracetamol)
• Antidiarrhoeal.
Alcohol
Post-withdrawal Management
GP options:
– retain in treatment, ongoing management
– seek referral.
Considerations:
– patient’s wants (abstinence or reduced
consumption, remaining your patient)
– severity of problems.
Pharmacotherapies:
– acamprosate
– naltrexone
– disulfiram (not PBS listed).
Alcohol
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.
Alcohol
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.
Alcohol
Clinical Guidelines
• Naltrexone 50 mg daily:
– indicated especially where
strong craving for alcohol
after a priming dose
–  likelihood of lapse
progressing to relapse
– LFTs < 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.
Alcohol
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 3–6 months
• Best results with supervised ingestion & contingency
management strategies.
Alcohol
SSRIs
•  alcohol consumption by 20% (low
dependence drinkers), effect wears off
after 1–2 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.
Alcohol