Alcohol information. A standard drink contains about 10g of alcohol takes a healthy liver about 1 hour to remove alcohol from the body.

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1 Alcohol information Facts about alcohol use Alcohol (grog) is the most widely used recreational drug in Australia NT drinks 70% more and WA 25% more than the rest of Australia Alcohol related deaths for Aboriginal people in Central Australia are 7 times higher, in the Kimberly 4 times higher, than the Australian average 48% of road deaths in NT, 26% in WA, 28% in SA involve a driver who has been drinking Ask about alcohol use when you Do Adult Health Checks, antenatal checks See people with injuries, STIs, or conditions that may be alcohol (grog) related See Brief interventions (p216). Always offer someone help to stop or cut down alcohol (grog) if they are drinking at risky or dangerous levels. Ask if alcohol (grog) use causes Trouble with police for alcohol-related crime Trouble with an employer, eg can t get to work on Mondays Trouble with relationships, eg family violence Safer drinking A standard drink contains about 10g of alcohol takes a healthy liver about 1 hour to remove alcohol from the body. 1 standard drink = 2 midis (285ml each) 1 can (375ml) 1 midi (285ml) light beer mid-strength beer full-strength beer 1 glass (100ml) wine 1 glass (60ml) port 1 nip (30ml) spirits 195 Mental health and drug problems

2 Alcohol information Table 3.2: Drinking levels No safe level of drinking for pregnant women. Standard drinks per day (men and women) Safe 0 2 Risky 3 4 Dangerous More than 4 Always try to have at least 2 days each week without alcohol (grog). Binge drinking (more than 6 8 drinks in a row) is very dangerous. Ideas for cutting down alcohol Drink slowly, don t scull, set a limit Drink water when thirsty Have non-alcoholic drinks in between Eat before drinking Take less money to the club/pub Start drinking later in the day Find ways to keep friends without drinking alcohol (grog) Do something else instead of going to the club/pub Talk with family and friends who don t drink for support Can light beer Can full-strength Carton (24) (375ml) beer (375ml) full-strength beers ~ 0.8 standard drink ~ 1½ standard drinks ~ 36 standard drinks (8g alcohol) (15g alcohol) (360g alcohol) Bottle spirits (750ml) Wine cask (2 litres) Port (2 litres) ~25 standard drinks ~ 20 standard drinks ~ 33 standard drinks (250g alcohol) (200g alcohol) (330g alcohol) 196

3 When person who usually drinks 80g or more of alcohol a day (8 or more standard drinks (p195)) stops drinking risk of dangerous alcohol withdrawal for the next 5 10 days. No safe level of drinking in pregnancy. Harmful effects include Fetal Alcohol Syndrome or Fetal Alcohol Spectrum Disorder (p116). Alcohol misuse may lead to Person being Drunk and angry acute alcohol intoxication and aggressive behaviour Drunk and passed out acute alcohol intoxication and unconscious Drunk and psychotic acute alcohol intoxication and acute psychosis OR Alcohol withdrawal uncomplicated, eg tremor, anxious, sweats etc DTs/ Horrors or fits severe alcohol withdrawal syndrome Drunk and angry Sometimes violent and dangerous (Aggressive people p171) Drunk and passed out Also think of other reasons for unconscious person (p87) May be medical problem or injury needing urgent care Drunk and psychotic Evident mental illness with loss of connection with external reality in person who has a history of alcohol dependence (Psychosis p189, or Mental health emergency p167) Alcohol withdrawal Usually starts 6 36 hours after last drink of alcohol (grog) Any combination of anxiety, agitation, fear, tremor, sweating, vomiting, diarrhoea, headache, can t sleep DTs/ Horrors or fits DTs (delirium tremens) can happen up to 6 days after stopping. Mix of anxiety, agitation, disorientation, dehydration risk of hyperthermia, possible death Withdrawal fits may happen in first 3 days after stopping alcohol Often happen because of other illness at the same time 197 Mental health and drug problems

4 Alcohol withdrawal Assess and manage based on the Alcohol Withdrawal Scale score AND other risk factors. Alcohol Withdrawal Scale (AWS) Add up the scores for all 7 criteria. This is the score for the person. Sweating 0. None 1. Moist damp skin 2. Sweat drops on face/chest 3. Sweat drops all over body 4. Clothes and bed wet with sweat Worries (anxiety) 0. None 1. A bit worried 2. Scared or worried 3. Worried, sometimes panics 4. Panics all the time Shakes (tremor) 0. None 1. Slight 2. Shaking hands 3. Shaking hands and feet Temp (under arm) o C o C o C o C 4. More than 38.5 o C Agitation 0. Rests OK 1. Awake at night, can t sit or lie still, wants to move all the time 2. Looks tense, wants to move all the time 3. Moving all the time, but will stay still if asked 4. Moving all the time, won t stop and is aggressive Orientation Knowing who they are, where they are and the time (knowing the time, eg hours or days of the week may not be appropriate, ask something local). 0. Person Place Time 1. Person Place? Time? 2. Person Place Time 3. Person? Place Time May be clear headed for short periods 4. Person Place Time They can t be reached Seeing things and hearing voices that are not there (hallucinations) 0. None 1. Real things seem different but they understand this isn t true 2. New things and feelings are coming but they understand they are not true 3. Believes new things and feelings are true but OK for person, place and time 4. In a totally new place and this can t be explained to them 198

5 Risk factors for complicated withdrawal Person has had withdrawal fits, DTs, severe withdrawal before, or many withdrawal episodes increased risk of a fit Significant illness, eg cellulitis, pneumonia, poorly controlled diabetes, heart condition Uses other drugs, eg opiates or benzodiazepines Drinking at a high level over a long period of time is more likely to lead to major withdrawal problems than bingeing and having a break Check AWS recheck every minutes until stable, condition may change quickly Temp, pulse, BP, RR Examine person carefully, look for other illnesses Do If having a fit see page 46 Check for other causes, eg head injury (p56), meningitis (p80), low BGL (p70) Make management plan Medical consult at beginning, regularly throughout withdrawal, any time you are concerned Doctor should seek advice from hotline (p202) if unsure Make sure a responsible person is with person at all times Look after person in severe withdrawal in quiet, not too bright room Give plenty of fluids watch for dehydration Give medicines Diazepam lessens agitation and other symptoms, eg hallucinations, helps prevent fits and DTs (Table 3.3 p201) Do not give diazepam until at least 6 8 hours after last alcohol (grog) Do not give diazepam if there may be a head injury or other medical cause for confusion Metoclopramide for nausea/vomiting oral/im 10mg every 6 8 hours Loperamide for diarrhoea Paracetamol for pain (p351) 199 Mental health and drug problems

6 If any chance they are a long term or regular heavy drinker of alcohol give thiamine IM 100mg daily for 5 days Then thiamine oral 100mg and 1 multivitamin daily for at least 1 month If person has a mental illness or epilepsy, make sure they take their usual medicines be aware that anti-psychotic medicines may make fits more likely If severe psychotic symptoms, not responding to diazepam, give Usual anti-psychotic medicine if on one (check file notes) OR Olanzapine oral 10 20mg (wafers preferred to tablets) OR Risperidone oral 2mg OR Haloperidol IM 5mg with benztropine IM 2mg but with care as they may make fits more likely May need to send to hospital if Had withdrawal fits or DTs in the past Signs of head injury (p56) or unconscious (p87) Significant other illness, eg pneumonia, poorly controlled diabetes T more than 38.5 o C, very fast pulse (p392), very high or low BP (p392) AWS score more than 7 Send to hospital urgently if AWS score more than 14 Getting worse AWS score increasing Not getting better after 12 hours AWS score not decreasing They have focal fits or 2 or more generalised fits Serious family or social problems that need sorting out in a more calm, controlled place Diazepam doses Always recheck AWS at least every 2 hours after giving diazepam to guide treatment If AWS increases, you may need to repeat or increase dose Medical consult if higher dose needed For old people, person with significant lung (acute or chronic) or liver disease, give half the dose and watch closely for over-sedation Medical consult before giving more than Oral 80mg in first 24 hours 90kg or under Oral 100mg in first 24 hours over 90kg 200

7 Table 3.3: Diazepam doses for alcohol withdrawal Alcohol problems acute Pattern of withdrawal Person has had withdrawal fits or DTs in past Mild AWS 1 4 AND no other risk factors Moderate to severe AWS 5 14 or less than 5 AND other risk factors (p199) Very Severe AWS more than 14 Diazepam doses and what to do Give diazepam oral 20mg every 2 hours until AWS less than 5 or sedated When AWS stays at less than 5 Give diazepam oral 10mg 4 times a day (qid) for 1 day Then taper dose to nothing over 3 5 more days May not need diazepam Can give diazepam if agitated Oral 5 10mg 3 4 times a day for 2 days Then taper dose to nothing over 3 5 more days Give diazepam oral 10 20mg every 2 hours until AWS less than 5 or sedated Base dose on how agitated person seems, eg Oral 10mg if AWS agitation score 1 3 Oral 20mg if AWS agitation score 4 When AWS stays at less than 5 Give diazepam oral 10mg 4 times a day (qid) for 1 day Then taper dose to nothing over 3 5 more days Give diazepam oral 20mg straight away Put in IV cannula (CRANA CPM p71) Send to hospital urgently Specialist consult Follow-up Medical consult every day until person stable Talk with person and family about social problems or depression that may be contributing to their problems Refer all people experiencing withdrawal to alcohol rehabilitation or counselling service Check pneumococcal and flu immunisation status give if needed (Australian Immunisation Handbook) Provide a brief intervention (p216) 201 Mental health and drug problems

8 Getting help 24 hour hotlines provide specialist advice to health professionals for dealing with alcohol and drug issues NT Drug and Alcohol Clinical Advisory Service, SA Alcohol and Drug Information Service, WA Alcohol and Drug Information Service,