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1 October 2013 Managing alcohol dependence in general practice i =

2 Addiction: Alcohol dependence In this module of Forum Clinical Challenge we look at the management of alcohol dependence in general practice Alcohol dependence issues for primary care GPs should maintain a high index of suspicion for the contributory or causative role of alcohol in a variety of clinical presentations As citizens and as healthcare professionals we are all too aware of our nation s unhealthy relationship with alcohol. The problem we face is a growing health and social crisis, costing an estimated 3.7 billion a year in health, public order and other costs. 1 But the cost of alcohol extends beyond monetary amounts. The figures are stark; alcohol is directly responsible for one in three road crash deaths and 1,200 cases of cancer each year in Ireland. 2 Alcohol also has a significant effect on mental health, with alcohol-related disorders being the third most common reason for admission to Irish psychiatric hospitals between 1996 and In addition to this, excess drinking has severe social implications with alcohol being a contributor to a staggering 97% of public order offences according to the Garda PULSE system. With the hazardous effects of alcohol so clear and well documented, assessing and attempting to change the harmful drinking attitudes of all of our patients needs to become as commonplace as checking blood pressure. Common clinical presentations Some patients will self-present for help and advice around alcohol use, but for those less forthcoming, the following presentations should raise a high index of suspicion: 3 Psychiatric Amnesia, memory disorders and dementia Anxiety and panic disorders Depressive illness Deliberate self harm Apparent treatment resistance Social Marital disharmony and domestic violence Child neglect Criminal behaviour Complications of unsafe sex Financial problems Homelessness Occupational Impaired work performance and accidents Poor employment record Physical Physical consequences as outlined in Table 3. 3

3 Table 1: DSM-IV Criteria for alcohol use disorders Criteria for alcohol abuse The patient s drinking has repeatedly caused/contributed to more than one of the following adverse consequences in the past 12 months: Risk of bodily harm (eg. drink driving) Problems with relationships Interference with home, work or school responsibilities Arrests or other legal problems Criteria for alcohol dependence The patient has had more than three of the following consequences in the past 12 months: Behavioural Repeatedly exceeded drinking limits Repeated failed attempts at cutting down/stopping Continued drinking despite recurrent physical/psychological problems Spent a lot of time drinking/recovering from drinking Spent less time on activities previously important or pleasurable Physiological Has shown tolerance Has had signs of withdrawal (Table 4) Alcohol dependence syndrome Drinking despite adverse consequences constitutes an alcohol use disorder. 4 Current criteria (Table 1), according to the DSM-IV, differentiate abuse from dependence but following recent research the new DSM-5 criteria will amalgamate the two disorders into one continuum, ranging from mild to severe. Assessment When at-risk drinking is suspected, assessment should include: Full history and physical examination Mental state examination Assessment for consumption pattern Assessment for criteria of alcohol-use disorders Screening/examination for Withdrawal (Table 4) Alcohol-related health problems (Table 3) Non-alcohol-related health problems Social problems. When addressing a patient s drinking problem it is also useful to ask about prior treatment of alcohol abuse, attempts to cut back and periods of sobriety. Careful questioning on the circumstances around recurrent drinking and relapses 5 can help to identify triggers; providing advice to avoid these triggers can reduce the risk of relapse. Risk drinking In Ireland, risk drinking is defined as drinking more than an average of 17 standard drinks a week for a male or 11 for a female. But the risk of harmful physical consequences of alcohol consumption exists on a spectrum where risk of consequences increases with units per week consumed (Table 2). Physical consequences There is a large number of conditions to which alcohol is a contributory or causative factor. The most common of these are listed systematically in Table 3. 4

4 Table 2: Definition of risk drinking Risk Men Women Common effects Low risk 17 standard drinks per week, with two alcohol-free days 11 standard drinks per week with two alcohol-free days Increased relaxation Sociability Increased risk standard drinks per week standard drinks per week Decreased energy Depression/anxiety Insomnia Impotence Risk of injury Hypertension All of the above and Memory loss Risk of liver disease Risk of malignancy Risk of alcohol dependence High risk 41 standard drinks per week 29 standard drinks per week Illustration of standard drinks courtesy of Alcohol withdrawal syndrome Alcohol withdrawal syndrome is due to hyperexcitability of the brain following a sudden drop of blood alcohol concentration. Its signs and symptoms are listed in Table 4. Severity of the syndrome can vary from mild, with symptoms such as sleep disturbance and anxiety, to severe and life-threatening, manifested by seizures and death. First signs and symptoms occur within hours of the last drink and peak within hours. In most alcohol-dependent individuals they are mild to moderate, and disappear within five to seven days after the last drink. Delirium tremens Commonly referred to as the DTs, delirium tremens is the most severe form of alcohol withdrawal. It can progress to cardiovascular collapse and is a medical emergency. It is characterised by: Nightmares Agitation, anxiety and paranoia Global confusion and disorientation Tremor Visual, auditory and tactile hallucinations Fever Autonomic hyperactivity. DTs can occur between three and 10 days after the last drink taken, occur in 5-10% of patients with alcohol dependence syndrome, and carry a mortality of 5-15% with treatment and up to 35% without treatment. 5

5 Table 3: Physical consequences of excessive alcohol intake Cardiorespiratory Haematological Endocrine/metabolic Atrial fibrillation Cardiomyopathy Hypertension Anaemia Coagulopathy Alcohol poisoning Electrolyte disturbances Infertility Malnutrition Gastrointestinal Neurological Malignancies Pancreatitis Alcoholic liver disease/cirrhosis Upper GI bleeding Gastritis Oesophagitis Oesophageal varices Genito-urinary Alcohol related STIs Crisis pregnancy Erectile dysfunction Kidney stones Peripheral neuropathy Wernicke s encephalopathy Seizures Cognitive impairment/ dementia Haemorrhagic stroke Musculoskeletal Gout Falls Fracture Injuries Oral/oesophageal Hepatic Pharyngeal Laryngeal Colorectal Breast Psychiatric consequences Alcohol-related disorders accounted for one in 10 first admissions to Irish psychiatric hospitals in 2011 and the link between alcohol use and psychiatric illness is well documented. But the difficulty when discussing the psychiatric consequences of alcohol is distinguishing between cause, effect and comorbidity. Alcohol has a number of psychiatric consequences, many of which mimic psychiatric disorders themselves, such as symptoms of depression and panic disorder. Conversely, we must not forget that many patients with psychiatric disorders may turn to alcohol as a method of self-medication and escape. Because alcohol can potentially mask or mimic signs and symptoms of mental disorders, it can often create a real diagnostic conundrum. Management Most alcohol-use disorders can be effectively managed in the primary care setting with further supports available in the community. Some patients should be considered for referral to their local psychiatric services or substance abuse programmes. Rarely, patients require inpatient hospital detoxification. Outpatient care has been proven to be equally as effective as inpatient treatment 6 with the exception of cases with complicating factors. Management plans can be decided based on: Whether the patient has developed alcohol dependence Whether the patient has withdrawal symptoms Whether the patient has factors that may complicate the withdrawal or cessation process. Brief interventions Brief interventions are extremely effective in a primary care setting. They have been shown to reduce consumption in hazardous drinkers without 6

6 Table 4: Signs and symptoms of alcohol withdrawal Nausea and vomiting Paroxysmal sweats Agitation Restlessness Fidgeting Auditory disturbances Startles easily Auditory hallucinations Headache/fullness in head Tremor Anxiety Tactile disturbances Pins and needles Itch Burning Numbness Tactile hallucinations Visual disturbances Sensitivity to light Visual hallucinations Disorientation alcohol dependence and to reduce alcohol-related harms and mortality. 7 Key components of brief interventions: Informing patients of their alcohol risk category and the potential harm associated Assessing a patient s readiness and planting seeds for change Establishing a new goal and giving advice on how to achieve it. Supervised withdrawal in primary care All withdrawals need general support and a proportion will need pharmacotherapy to modify the withdrawal-induced neuroexcitability. Signs and symptoms of alcohol withdrawal should be assessed (Table 4) and assigned a score depending on whether they are mild to severe. The scores are added up to give an Alcohol Withdrawal Score (AWS). The most widely used tool example is the Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) 8 which grades withdrawal from mild to severe. Most withdrawals can be managed safely and effectively at home under the supervision of the GP, but referral to medical or psychiatric services should be considered under the following circumstances. 9 Consider A&E or medical services when: Confusion or hallucinations in any modality History of complicated withdrawal History of seizure disorder History of medications lowering seizure threshold Acute physical concurrent illness Uncontrollable withdrawal symptoms. Consider psychiatric services or substance abuse programmes when: Acute psychiatric illness or suicidality Daily consumption of >20 standard drinks History of failed home-assisted withdrawals Polysubstance abuse. Supplementation and symptomatic pharmacotherapy Vitamin supplements, such as thiamine, should be offered as prophylaxis against Wernicke-Korsakoff syndrome. Adequate fluid intake should be encouraged to maintain hydration and electrolyte balance. Paracetamol, metoclopramide and anti- 7

7 histamines may be useful in alleviating withdrawal symptoms. Cautious use of benzodiazepines Benzodiazepines are the most commonly used drugs for management of withdrawal. Chlordiazepoxide is the drug of choice in uncomplicated withdrawal as it has relatively low dependenceforming potential. 10 In the community a fixed-dose regimen should be used: The starting dose of benzodiazepine should be selected once severity of alcohol dependence is assessed (clinical history, number of units per drinking day, score on CIWA-Ar) The dose is then tapered to zero over seven days. Mild alcohol dependence usually requires small doses of chlordiazepoxide or may be managed with no medication. A typical regimen for moderate dependence might be 10-20mg chlordiazepoxide QDS, reducing gradually over five to seven days. Severe alcohol dependence usually requires referral for specialist or inpatient treatment. Examples of fixed dose regimens can be found based on NICE guidelines at: The NICE clinical guidelines GC and GC are useful to refer to and, for community-based management of withdrawal, suggest: Prescribing chlordiazepoxide for instalment dispensing, with no more than two days medication supplied at any time Monitoring the patient every other day Suggesting that a family member/carer oversees the administration of medication. Management outside primary care Further services are available in various formats nationwide that provide a supportive environment for achievement and maintenance of sobriety: Community-based addiction counselling Intensive outpatient programmes Residential programmes Group therapy/meetings Individual therapy. Pharmacotherapy According to recent evidence, relapse prevention medication should be considered for all alcohol dependent patients who wish to become abstinent. 13 Recommended medications 13 for preventing relapse and maintaining abstinence include: Acamprosate, which can be used to improve abstinence rates. Since there is evidence that it reduces alcohol consumption, if the patient starts drinking, it should be continued provided there is overall patient benefit. Avoid in renal impairment with creatinine clearance <30ml/min. Recommended dose 666mg PO TDS (333mg PO TDS renal dose necessary in renal impairment) Naltrexone can be used to reduce risk of relapse. However, there is less evidence to support its use in maintaining abstinence. It should not be used with opioid analgesia. Recommended dose 50mg OD PO Disulfiram is effective if intake is witnessed. There is less evidence base than for acamprosate and naltrexone. It should be offered as a treatment option for patients who intend to maintain abstinence, so long as there are no contraindications (eg. use of alcohol, treatment with metronidazole, heart disease). Must monitor LFTs and avoid alcohol in diet, toiletries etc. Recommended dose mg PO OD. The Irish Medicines Board website has product datasheets for these medications. Dr Ruth McCullough is an intern, Dr Clodagh Quinn, registrar and Prof Jogin Thakore, is consultant psychiatrist, at St Vincent s Hospital, Fairview, Dublin 8

8 Case studies: examples and discussion points CASE 1 A 41-year-old woman presented to the clinic for review as she had been suffering with a low mood for the previous six months. She described sleep disturbance most nights and often an inability to get out of bed in the morning. She felt her mood was worst in the morning but then improved over the course of the day. She had still been managing to get out to meet friends but had a reduced interest in other activities that she had previously enjoyed. She also described intermittent anxiety symptoms and had experienced a number of panic attacks in recent weeks. She noted that she had tried several antidepressant medications since presenting to her GP but had experienced no improvement in her symptoms. On further discussion, it emerged that the woman would meet with her friends at their homes to share a few glasses of wine four to five nights a week and, on average, she was drinking three to four large glasses of wine each night. She felt that this was not really an issue as this was her primary social outlet and she enjoyed it greatly. On calculation she was drinking anything up to 40 units of alcohol a week and up to 12 units in one evening, which would qualify her as having a harmful alcohol intake, perhaps even with some subtle signs of dependence beginning to develop. When it was suggested that this intake of alcohol was in excess of the recommended amount, she became quite dismissive, but after going through the various information available, she was counselled on the guidelines for alcohol intake in the format of a brief intervention. It was also suggested to her that her symptoms may be a consequence of this harmful intake and that the alcohol could interfere with the efficacy of the antidepressant medications. Afterwards, she was agreeable to attempt to decrease her intake, and was provided with information for local substance abuse counselling. Discussion points There are some very useful learning points in this case. It shows the importance of taking a detailed alcohol intake history. This woman s just a few glasses of wine with friends translated to an intake markedly above the recommended level that could easily have been overlooked. This case also demonstrates how harmful alcohol use can mimic a psychiatric disorder but also interfere with treatment. This woman was entirely unaware that her symptoms were possibly related to her alcohol intake. Some months later, she presented with a marked improvement 9

9 in mental state/mood having significantly reduced her alcohol intake. Another point which must be considered is that many patients with an underlying mental health disorder may use alcohol to alleviate their symptoms and that often times there could be a dual diagnosis of a mental health disorder and an alcohol abuse problem. CASE 2 A 58-year-old man presented to the hospital complaining of withdrawal symptoms and expressing interest in engaging in an alcohol detoxification programme. He reported that he had been drinking heavily on and off for 20 years, and that he had experienced only brief periods of sobriety during this time. This man was estranged from his family and had become unemployed in the preceding few years and felt that he was ready to change things. His alcohol intake varied, depending on how much money he had, but he drank an average of eight to 20 cans of lager a day throughout the 20 years. He began drinking from the morning and described several blackout episodes but these typically happened when he was intoxicated. He described marked withdrawal symptoms of sweating, nausea, tremor, headache and visual hallucinations if he didn t drink. He was extremely unkempt and thin. His physical exam was normal and he did not show any signs of chronic liver disease. It was decided that he required a residential detoxification programme on the basis that he had had multiple failed attempts in the past and needed more intensive support to achieve abstinence. Discussion points This case demonstrates a typical presentation to the services. This man has failed on many occasions to remain abstinent from alcohol. His problem has had a significant impact on him, both socially and medically and he would be likely to fail to achieve and maintain abstinence with a typical outpatient programme. There are multiple options available when considering where to refer a patient in these circumstances. If there are medical concerns (ie. previous history of seizures when in withdrawal or of other severe medical problems), then a patient should be referred to the local hospital for medical assessment and/ or inpatient detoxification. If there are no medical concerns, then there are residential programmes and various intensive community based/outpatient-based counselling programmes available. Websites such as and ie can be useful in finding the local counselling services. It is always an option to contact your local psychiatric services for more information on the alcohol-use programmes, both public and private, that are available in your local area. CASE 3 A 26-year-old girl presented with her partner, in an extremely agitated and distressed state. She had a background history of impulsive behaviour and multiple episodes of self-harm and she was presenting with acute self-harm and suicidal ideation. During the interview, this young girl s behaviour became increasingly agitated and impulsive, and it became apparent that she was intoxicated, 10

10 challenge and had been consuming up to two litres of vodka daily during the preceding weeks. It was not possible to elicit if she had taken any other substances that day or to decipher any of her previous psychiatric or medical history. It was considered possible that she had a diagnosis of borderline personality disorder, with concurrent harmful alcohol use and possible alcohol dependence, but she could not be fully assessed in an intoxicated state. She was referred urgently to the nearest emergency department for medical assessment and toxicology screening and was later admitted for crisis support and alcohol detoxification. It later emerged that she had a long history of symptoms of low mood and deliberate self-harm, with several similar presentations to other hospitals. Discussion points This was a difficult case but is a good example of the link between harmful alcohol use and suicidal ideation and deliberate self-harm, which is well established. A study of suicide in Ireland found that half of those who died by suicide had abused alcohol in the previous 12 months, 14 and it was a factor in 40% of all cases of self-harm in The WHO has estimated that the risk of suicide in those currently abusing alcohol is eight times greater than non-alcohol-abusers. References 1 Hope A. Alcohol-related harm in Ireland. Health Services Executive, Health Research Board, Alcohol: Public Knowledge, Attitudes and Behaviours. Report Scottish Intercollegiate Guidelines Network 2003, Homepage of Scottish Intercollegiate Guidelines Network. Available: 4. Diagnostic and Statistical Manual of Mental Disorders, 4th ed, text revision. Washington, DC: American Psychiatric Association, Friedmann PD, Saitz R, Samet JH. Management of adults recovering from alcohol or other drug problems: relapse prevention in primary care. JAMA 1998; 279: Hayashida M, Alterman AI, McLellan AT et al. Comparative effectiveness and costs of inpatient and outpatient detoxification of patients with mild-tomoderate alcohol withdrawal syndrome. N Engl J Med Feb 9;320(6): Jonas DE, Garbutt JC, Amick HR et al. Behavioral counseling after screening for alcohol misuse in primary care: a system- atic review and meta-analysis for the U.S. Preventive Services Task Force. Ann In- tern Med 2012;157: Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM. Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar). Br J Addict. Nov 1989;84(11): Scottish Intercollegiate Guidelines Network 2003, Homepage of Scottish Intercollegiate Guidelines Network Taylor D, Paton C, Kapur Shitij. The Maudsley Prescribing Guidelines in Psychiatry. 11th Edition Linfgord-Hughes et al. BAP updated guidelines: evidence-based guidelines for the pharmacological management of substance abuse, harmful use, addiction and comorbidity: recommendations from BAP. Journal of Pychopharmacology 2012;26: Kevin M. Malone, Suicide in Ireland Bradley KA, DeBenedetti AF, Volk RJ et al. AUDIT- C as a brief screen for alcohol mis-use in primary care. Alcohol Clin Exp Res 2007;31: Forum Clinical Challenge: Alcohol Dependence. Vol 4, No 3. This module was published as a supplement to Forum, Journal of the ICGP, October 2013 The contents in full are Copyright of MedMedia Ltd. No articles may be reproduced, either in full or part, without the prior written permission of the publishers. This healthcare professional education is sponsored by Lundbeck Ireland Ltd. Lundbeck Ireland Ltd. had no editorial oversight of the final content.

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