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Alcohol use disorders
ALCOHOL AND OTHER DRUG DISORDERS
Alcohol use disorders
What’s new?
James Bell C
C
Abstract The medical manifestations of alcohol are protean. A drinking history and high index of suspicion for alcohol misuse is part of comprehensive medical assessment. Identification of hazardous and harmful drinking, and provision of brief advice and brief intervention if indicated, should occur in any episode of healthcare. In acute settings, prevention and management of alcohol withdrawal, and of Wernicke’s encephalopathy, are key priorities. In community settings, long-term management of alcohol dependence through regular monitoring and feedback is an effective way to manage many alcohol-dependent patients.
C
C
C
Alcohol and other psychoactive drugs produce reinforcing effects by acting on the ‘reward pathway’ In dependent drinkers, chronic alcohol exposure produces lasting central nervous system changes, placing people at longterm risk of relapse Medical practitioners providing brief advice, monitoring and feedback to patients can produce sustained benefits in a proportion of harmful drinkers Wernicke’s encephalopathy is a medical emergency requiring supra-physiological doses of parenteral thiamine Hospitals should have local protocols for managing alcohol withdrawal, use screening questionnaires to identify people whose drinking is placing their health at risk, and use withdrawal scales to monitor admitted patients who are at risk of alcohol withdrawal
Keywords alcohol dependence; alcohol use disorder; alcohol withdrawal; brief intervention; harmful drinking; hazardous drinking; WernickeeKorsakoff syndrome
consumption has increased over the last two decades, and diseases due to the effects of chronic alcohol consumption have also increased. UK survey data suggest that approximately 7.1 million people in England (23% of the population aged 16e64) drink hazardously or harmfully, and 1.1 million people are dependent on alcohol. Within the UK, the prevalence of alcohol-related violence and injuries is related to the number and density of alcohol outlets and the licensing hours.2 Deprived areas suffer higher levels of alcohol-related mortality, hospital admissions, crime, absence from work, school exclusions, teenage pregnancy and road traffic accidents, linked to greater levels of alcohol consumption.
Definition Current guidelines recommend that people should not regularly drink more than the daily unit limits: 3e4 units of alcohol for men (equivalent to a pint and a half of 4% v/v beer) and 2e3 units of alcohol for women (equivalent to a 175-mL glass of wine). Drinking above this level constitutes hazardous drinking, as it increases the risk of harmful consequences for the user. Hazardous use refers to patterns of use that are of public health significance despite the absence of any current disorder in the individual user.1
Pathology and pathogenesis
Harmful drinking: is defined as a pattern of alcohol consumption causing health problems directly related to alcohol.1 The commonest consequences of harmful drinking result from acute intoxication, which is estimated to contribute to 1 million alcohol-related attendances to emergency departments (ED) in England on Friday and Saturday nights alone. The top 10 presentations are fall, collapse, head injury, assault, accident, generally unwell, gastrointestinal symptoms, cardiac symptoms, psychiatric problems (especially self-harm) and frequent attendance.
Alcohol, like other reinforcing drugs, produces effects in the brain ‘reward pathway’, an array of neural systems involving dopaminergic transmission and endorphin release. Drugs acting on this pathway reduce anxiety, and induce a sense of well-being and confidence. Neurobiological research suggests that the chronic administration of alcohol and other drugs produces enduring changes in brain neurotransmitter systems that leave the user vulnerable to relapse after abstinence has been achieved, on this basis, it is suggested that alcohol dependence should be viewed as a chronic, relapsing brain disease.3
Course of the disease
Alcohol dependence: is a behavioural syndrome of impaired control over alcohol use, with drinking becoming habitual and problematic. The most reliable diagnostic feature is the presence of withdrawal symptoms and signs when alcohol is stopped or reduced. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) provides criteria for making the diagnosis (Table 1). This article will focus primarily on three issues of importance to all medical practitioners e identification and brief intervention, management of withdrawal, and prevention of WernickeeKorsakoff syndrome (WeKS). However, it is also important to know when to refer to specialist services (e.g. for planned detoxification and relapse prevention).
Contrary to prevailing medical pessimism, many dependent drinkers stop drinking or return to controlled, low-risk drinking.4 Whereas a proportion of more severely affected individuals seeking treatment will progress to a relapsing, remitting condition, follow-up studies suggest quite good outcomes for treatment of alcohol dependence, with 50e60% of men and women with alcohol dependence abstaining or showing substantial improvements in functioning during the year after treatment.5 The course of alcohol-related disease depends on whether people cease drinking. Neurological damage due to alcohol is usually considered irreversible, although cessation of drinking can slow or halt disease progression. The 10-year survival of patients presenting with compensated alcohol-related cirrhosis, who remained abstinent or who substantially reduced their intake, was around 60%, compared to around 30% in those who continued to drink. The respective figures in those with decompensated cirrhosis were 50% and less than 10%.5
Epidemiology The incidence of alcohol-related disease in populations rises with increasing per capita alcohol consumption. In the UK, per capita
Diagnosis
James Bell FRACP FAChAM MD is a Consultant Addiction Physician, Kings Health Partners, London, UK. His research interest is treatment of drug dependence. Conflicts of interest: none declared.
MEDICINE 40:12
Medical assessment should include a drinking history, knowledge of the potential adverse health effects of alcohol, and ability to interpret
637
Crown Copyright Ó 2012 Published by Elsevier Ltd. All rights reserved.
ALCOHOL AND OTHER DRUG DISORDERS
Managing withdrawal
DSM Diagnostic Criteria for alcohol dependence.15
Successive episodes of alcohol withdrawal are associated with an increased severity of withdrawal and rate of complications, and with cognitive impairment; the priority is to prevent withdrawal by anticipation, monitoring and early initiation of treatment with long-acting benzodiazepines.11 Hospitals should have readily accessible protocols for monitoring and managing withdrawal. Benzodiazepines can precipitate hepatic encephalopathy, and management of people with decompensated liver disease who are withdrawing from alcohol withdrawal should involve consultation with a healthcare professional experienced in the management of patients with liver disease (see also Drugs for alcohol dependence on pages 686e687 of this issue) (Table 2). Many dependent drinkers can stop drinking without experiencing severe withdrawal. However, the presence of intercurrent illness, such as trauma, fever, or hypoxia, can contribute to severe withdrawal. Alcohol withdrawal begins within approximately 8 h of abstinence and peaks in intensity on the second or third day; symptoms usually diminish by the fourth or fifth day. Seizures tend to occur early in the course of withdrawal. All heavy drinkers admitted to hospital should be monitored for the emergence of symptoms and signs indicating withdrawal, and many hospitals use a structured withdrawal scale, such as the Clinical Institute Withdrawal Scale (CIWA)12 or Alcohol Withdrawal Scale (AWS),13 to monitor withdrawal symptoms. Hospital staff should be familiar with the use and interpretation of an alcohol withdrawal scale.1 Admission to hospital for medically assisted withdrawal should be offered to: people assessed to be at high risk of developing alcohol withdrawal seizures or delirium tremens vulnerable people (e.g. those who are frail, have cognitive impairment or co-morbidities, lack social support, have learning difficulties, or are aged 16 or 17 years).9 After withdrawal, dependent drinkers may benefit from medication e usually either acamprosate or naltrexone e to assist in relapse prevention.1
DSM-IV diagnosis of alcohol dependence requires that a patient must meet at least three out of the following seven criteria during a 12-month period C Tolerance C Withdrawal symptoms or clinically defined Alcohol Withdrawal Syndrome C Use in larger amounts or for longer periods than intended e Persistent desire or unsuccessful efforts to cut down on alcohol use C Time is spent obtaining alcohol or recovering from effects C Social, occupational and recreational pursuits are given up or reduced because of alcohol use C Use is continued despite knowledge of alcohol-related harm (physical or psychological) Table 1
laboratory investigations. Useful and widely available biological markers of alcohol misuse include a raised g-glutamyl transferase (GGT), which has a sensitivity and specificity approaching 60% in men, and 50% in women.6 History taking must be undertaken sensitively, with respect for the patients’ privacy, dignity and confidentiality.1 Patients, particularly those who drink excessively and who are not seeking treatment for it, are often defensive and understate their intake. Alcohol use disorders (AUDs) are common. However, most people with alcohol-related problems present with general complaints such as insomnia, anxiety, sadness, or a range of medical problems.5 For these reasons screening tests for AUDs are recommended. NHS staff should be familiar with the Alcohol Use Disorder Identification Test (AUDIT7), a brief screening questionnaire. Patients scoring 8e14 on AUDIT are at risk of alcohol-related problems, and should receive brief advice and follow-up. Patients scoring more than 14 on AUDIT should receive brief advice and be referred for comprehensive assessment. Those scoring 20 or more should be referred for assessment and management of anticipated withdrawal.1
WernickeeKorsakoff syndrome (WeKS) results from a deficiency in vitamin B1 (thiamine) and is characterized by nystagmus and ophthalmoplegia, mental-status changes, and unsteadiness of stance and gait, symptoms that are difficult to distinguish from intoxication. This classical triad is seen in only 16% of
Differential diagnosis The differential diagnosis of alcohol withdrawal is alcohol intoxication, Wernicke’s encephalopathy, and other causes of delirium e notably, hepatic encephalopathy, post-ictal state, head injury, and effects of other psychoactive drugs.
Features of alcohol withdrawal Alcohol withdrawal is characterized by three primary symptom clusters: C Sympathetic nervous system overactivity e raised pulse, blood pressure, sweating, tremor, and temperature C Perceptual disturbances These may be visual, tactile, or, more rarely, auditory. Visual disturbances range from vivid dreams to illusions (misperceiving objects in the environment), to frank hallucinations (seeing objects that are not present). Tactile disturbances (formication, the sensation of things crawling on the skin) are not rare. C Cognitive changes ranging from anxiety to paranoia, and delirium
Management Management of dependence/harmful drinking The medical practitioner’s role is to identify, monitor and give feedback on alcohol use and health consequences in their patients. Such brief intervention has been ranked as the most effective of all treatments for drinking problems.8 In the UK, all health professionals are advised to implement early identification and brief advice (IBA), using presentation for healthcare as a ‘teachable moment’. Clinicians should link their presentation to the patient’s alcohol use and offer a 20e40-min consultation with an alcohol specialist nurse.9 Follow-up monitoring by GPs or other services is also important. Screening using GGT to identify heavy drinkers, then monitoring GGT concentration and providing patients with feedback, has been shown to produce short-term differences in drinking and hospitalization, and long-term reduction in deaths due to alcoholrelated causes.10
MEDICINE 40:12
In addition, alcohol withdrawal is characterized by insomnia, and gastrointestinal disturbances (nausea and vomiting). Seizures may occur early in the course of alcohol withdrawal Table 2
638
Crown Copyright Ó 2012 Published by Elsevier Ltd. All rights reserved.
ALCOHOL AND OTHER DRUG DISORDERS
2 Babor TF, Caetano R, Casswell S, et al. Alcohol: no ordinary commoditydresearch and public policy. Oxford: Oxford University Press, 2003. 3 Gunzerath L, Hewitt BG, Li TK, Warren KR. Alcohol research: past, present, and future. Ann New York Acad Sci 2011; 1216: 1e23. 4 Dawson DA, Grant BF, Stinson FS, et al. Recovery from DSM-IV alcohol dependence: United States, 2001e2002. Addiction 2005; 100: 281e92. 5 Shuckitt M. Alcohol use disorders. Lancet 2009; 373: 492e501. 6 Conigrave KM, Degenhardt LJ, Whitfi eld JB, et al. CDT, GGT, and AST as markers of alcohol use: the WHO/ISBRA collaborative project. Alcohol Clin Exp Res 2002; 26: 332e9. 7 Saunders JB, Aaasland OG, Babor TF, de la Fuente JR, Grant M. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption. Addiction 1993; 88: 791e804. 8 Miller WR, Wilbourne PL. Mesa Grande: a methodological analysis of clinical trials of treatments for alcohol use disorders. Addiction 2002; 97: 265e77. 9 NICE. Alcohol use disorders: diagnosis and clinical management of alcohol-related physical complications, www.nice.org.uk/guidance/ CG100; 2010. 10 Kristenson H, Sterling A, Nilsson J, Lindg€arde F. Prevention of alcoholrelated deaths in middle-aged heavy drinkers. Alcohol Clin Exp Resl 2002; 26: 478e84. 11 Lingford-Hughes A, Welch S, Nutt D. Evidence-based guidelines for the pharmacological management of substance misuse. Addict Comorbidity: Recommendations Br Assoc Psychopharmacol J Psychopharmacol 2004; 18: 293. 12 Shaw JM. Development of optimal treatment tactics for alcohol withdrawal. I: assessment and effectiveness of supportive care. J Clin Psychopharmacol 1981; 1: 382e7. 13 Saunders JB. Drug treatment in alcoholism. In: Burrow GD, Norman TR, eds. Drugs in Psychiatry, vol. 4. Amsterdam: Elsevier, 1987; 343e369. 14 Sechi G, Serra A. Wernicke’s encephalopathy: new clinical settings and recent advances in diagnosis and management. Lancet Neurol 2007; 6: 442e55. 15 American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th edn. Washington: DC, text revision, 2000.
patients. In Western societies, WeKS is usually observed in heavy drinkers, and autopsy studies indicate that the diagnosis was missed in 75 e80% of cases. About 80% of patients with Wernicke’s encephalopathy who survive develop Korsakoff’s syndrome, a disabling disorder characterized by severe memory defects. WeKS is a medical emergency, and doses of thiamine between 100 mg and 250 mg per day apparently may not restore central nervous system vitamin status or improve clinical signs.14 Patients who have signs indicative of Wernicke’s encephalopathy should be treated empirically with high-dose parenteral thiamine given three times daily for 2e3 days.
Prognosis and explanation People with alcohol-related disease should be advised that their prognosis depends on ceasing or reducing drinking. Most clinicians recommend long-term abstinence for dependent drinkers, due to the risk of relapse and rapid re-instatement of dependent drinking. However, in patients not willing to consider this, reducing levels of alcohol consumption may also produce significant health benefits.
Follow-up Whether with hospital services, local specialist services, or with the GP, follow-up should be offered to all patients with alcohol dependence or alcohol-related disease. People identified as drinking above safe levels should be reviewed by their GP.
Prevention Doctors should offer prophylactic parenteral thiamine followed by oral thiamine to harmful or dependent drinkers: if they are malnourished or at risk of malnourishment or they have decompensated liver disease and in addition they attend an emergency department or are admitted to hospital with an acute illness or injury.9
A REFERENCES 1 NICE. NICE clinical guideline 115 alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence, www.nice.org.uk/guidance/CG115; 2011.
Practice points Task C Identification
Action Alcohol history, diagnosis, screening questions (e.g. AUDIT)
Knowledge Alcohol content of drinks, alcohol-related disease, biological markers
Skill Sensitive to stigma, preserve privacy and dignity
C
Prevent complications
Prophylactic thiamine, monitor withdrawal manage withdrawal Manage WeKS
Signs and symptoms of withdrawal, WernickeeKorsakoff
Vigilance regarding risk, use of withdrawal scales (e.g. CIWA) Differential diagnosis
C
Provide advice and arrange FU
Give feedback on health risks, prognosis. Refer for specialist follow up
Recommended levels of drinking Local referral agencies
Judgemental or critical responses are often counterproductive
MEDICINE 40:12
639
Crown Copyright Ó 2012 Published by Elsevier Ltd. All rights reserved.
Alcohol use disorders
What’s new?
James Bell C
C
Abstract The medical manifestations of alcohol are protean. A drinking history and high index of suspicion for alcohol misuse is part of comprehensive medical assessment. Identification of hazardous and harmful drinking, and provision of brief advice and brief intervention if indicated, should occur in any episode of healthcare. In acute settings, prevention and management of alcohol withdrawal, and of Wernicke’s encephalopathy, are key priorities. In community settings, long-term management of alcohol dependence through regular monitoring and feedback is an effective way to manage many alcohol-dependent patients.
C
C
C
Alcohol and other psychoactive drugs produce reinforcing effects by acting on the ‘reward pathway’ In dependent drinkers, chronic alcohol exposure produces lasting central nervous system changes, placing people at longterm risk of relapse Medical practitioners providing brief advice, monitoring and feedback to patients can produce sustained benefits in a proportion of harmful drinkers Wernicke’s encephalopathy is a medical emergency requiring supra-physiological doses of parenteral thiamine Hospitals should have local protocols for managing alcohol withdrawal, use screening questionnaires to identify people whose drinking is placing their health at risk, and use withdrawal scales to monitor admitted patients who are at risk of alcohol withdrawal
Keywords alcohol dependence; alcohol use disorder; alcohol withdrawal; brief intervention; harmful drinking; hazardous drinking; WernickeeKorsakoff syndrome
consumption has increased over the last two decades, and diseases due to the effects of chronic alcohol consumption have also increased. UK survey data suggest that approximately 7.1 million people in England (23% of the population aged 16e64) drink hazardously or harmfully, and 1.1 million people are dependent on alcohol. Within the UK, the prevalence of alcohol-related violence and injuries is related to the number and density of alcohol outlets and the licensing hours.2 Deprived areas suffer higher levels of alcohol-related mortality, hospital admissions, crime, absence from work, school exclusions, teenage pregnancy and road traffic accidents, linked to greater levels of alcohol consumption.
Definition Current guidelines recommend that people should not regularly drink more than the daily unit limits: 3e4 units of alcohol for men (equivalent to a pint and a half of 4% v/v beer) and 2e3 units of alcohol for women (equivalent to a 175-mL glass of wine). Drinking above this level constitutes hazardous drinking, as it increases the risk of harmful consequences for the user. Hazardous use refers to patterns of use that are of public health significance despite the absence of any current disorder in the individual user.1
Pathology and pathogenesis
Harmful drinking: is defined as a pattern of alcohol consumption causing health problems directly related to alcohol.1 The commonest consequences of harmful drinking result from acute intoxication, which is estimated to contribute to 1 million alcohol-related attendances to emergency departments (ED) in England on Friday and Saturday nights alone. The top 10 presentations are fall, collapse, head injury, assault, accident, generally unwell, gastrointestinal symptoms, cardiac symptoms, psychiatric problems (especially self-harm) and frequent attendance.
Alcohol, like other reinforcing drugs, produces effects in the brain ‘reward pathway’, an array of neural systems involving dopaminergic transmission and endorphin release. Drugs acting on this pathway reduce anxiety, and induce a sense of well-being and confidence. Neurobiological research suggests that the chronic administration of alcohol and other drugs produces enduring changes in brain neurotransmitter systems that leave the user vulnerable to relapse after abstinence has been achieved, on this basis, it is suggested that alcohol dependence should be viewed as a chronic, relapsing brain disease.3
Course of the disease
Alcohol dependence: is a behavioural syndrome of impaired control over alcohol use, with drinking becoming habitual and problematic. The most reliable diagnostic feature is the presence of withdrawal symptoms and signs when alcohol is stopped or reduced. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) provides criteria for making the diagnosis (Table 1). This article will focus primarily on three issues of importance to all medical practitioners e identification and brief intervention, management of withdrawal, and prevention of WernickeeKorsakoff syndrome (WeKS). However, it is also important to know when to refer to specialist services (e.g. for planned detoxification and relapse prevention).
Contrary to prevailing medical pessimism, many dependent drinkers stop drinking or return to controlled, low-risk drinking.4 Whereas a proportion of more severely affected individuals seeking treatment will progress to a relapsing, remitting condition, follow-up studies suggest quite good outcomes for treatment of alcohol dependence, with 50e60% of men and women with alcohol dependence abstaining or showing substantial improvements in functioning during the year after treatment.5 The course of alcohol-related disease depends on whether people cease drinking. Neurological damage due to alcohol is usually considered irreversible, although cessation of drinking can slow or halt disease progression. The 10-year survival of patients presenting with compensated alcohol-related cirrhosis, who remained abstinent or who substantially reduced their intake, was around 60%, compared to around 30% in those who continued to drink. The respective figures in those with decompensated cirrhosis were 50% and less than 10%.5
Epidemiology The incidence of alcohol-related disease in populations rises with increasing per capita alcohol consumption. In the UK, per capita
Diagnosis
James Bell FRACP FAChAM MD is a Consultant Addiction Physician, Kings Health Partners, London, UK. His research interest is treatment of drug dependence. Conflicts of interest: none declared.
MEDICINE 40:12
Medical assessment should include a drinking history, knowledge of the potential adverse health effects of alcohol, and ability to interpret
637
Crown Copyright Ó 2012 Published by Elsevier Ltd. All rights reserved.
ALCOHOL AND OTHER DRUG DISORDERS
Managing withdrawal
DSM Diagnostic Criteria for alcohol dependence.15
Successive episodes of alcohol withdrawal are associated with an increased severity of withdrawal and rate of complications, and with cognitive impairment; the priority is to prevent withdrawal by anticipation, monitoring and early initiation of treatment with long-acting benzodiazepines.11 Hospitals should have readily accessible protocols for monitoring and managing withdrawal. Benzodiazepines can precipitate hepatic encephalopathy, and management of people with decompensated liver disease who are withdrawing from alcohol withdrawal should involve consultation with a healthcare professional experienced in the management of patients with liver disease (see also Drugs for alcohol dependence on pages 686e687 of this issue) (Table 2). Many dependent drinkers can stop drinking without experiencing severe withdrawal. However, the presence of intercurrent illness, such as trauma, fever, or hypoxia, can contribute to severe withdrawal. Alcohol withdrawal begins within approximately 8 h of abstinence and peaks in intensity on the second or third day; symptoms usually diminish by the fourth or fifth day. Seizures tend to occur early in the course of withdrawal. All heavy drinkers admitted to hospital should be monitored for the emergence of symptoms and signs indicating withdrawal, and many hospitals use a structured withdrawal scale, such as the Clinical Institute Withdrawal Scale (CIWA)12 or Alcohol Withdrawal Scale (AWS),13 to monitor withdrawal symptoms. Hospital staff should be familiar with the use and interpretation of an alcohol withdrawal scale.1 Admission to hospital for medically assisted withdrawal should be offered to: people assessed to be at high risk of developing alcohol withdrawal seizures or delirium tremens vulnerable people (e.g. those who are frail, have cognitive impairment or co-morbidities, lack social support, have learning difficulties, or are aged 16 or 17 years).9 After withdrawal, dependent drinkers may benefit from medication e usually either acamprosate or naltrexone e to assist in relapse prevention.1
DSM-IV diagnosis of alcohol dependence requires that a patient must meet at least three out of the following seven criteria during a 12-month period C Tolerance C Withdrawal symptoms or clinically defined Alcohol Withdrawal Syndrome C Use in larger amounts or for longer periods than intended e Persistent desire or unsuccessful efforts to cut down on alcohol use C Time is spent obtaining alcohol or recovering from effects C Social, occupational and recreational pursuits are given up or reduced because of alcohol use C Use is continued despite knowledge of alcohol-related harm (physical or psychological) Table 1
laboratory investigations. Useful and widely available biological markers of alcohol misuse include a raised g-glutamyl transferase (GGT), which has a sensitivity and specificity approaching 60% in men, and 50% in women.6 History taking must be undertaken sensitively, with respect for the patients’ privacy, dignity and confidentiality.1 Patients, particularly those who drink excessively and who are not seeking treatment for it, are often defensive and understate their intake. Alcohol use disorders (AUDs) are common. However, most people with alcohol-related problems present with general complaints such as insomnia, anxiety, sadness, or a range of medical problems.5 For these reasons screening tests for AUDs are recommended. NHS staff should be familiar with the Alcohol Use Disorder Identification Test (AUDIT7), a brief screening questionnaire. Patients scoring 8e14 on AUDIT are at risk of alcohol-related problems, and should receive brief advice and follow-up. Patients scoring more than 14 on AUDIT should receive brief advice and be referred for comprehensive assessment. Those scoring 20 or more should be referred for assessment and management of anticipated withdrawal.1
WernickeeKorsakoff syndrome (WeKS) results from a deficiency in vitamin B1 (thiamine) and is characterized by nystagmus and ophthalmoplegia, mental-status changes, and unsteadiness of stance and gait, symptoms that are difficult to distinguish from intoxication. This classical triad is seen in only 16% of
Differential diagnosis The differential diagnosis of alcohol withdrawal is alcohol intoxication, Wernicke’s encephalopathy, and other causes of delirium e notably, hepatic encephalopathy, post-ictal state, head injury, and effects of other psychoactive drugs.
Features of alcohol withdrawal Alcohol withdrawal is characterized by three primary symptom clusters: C Sympathetic nervous system overactivity e raised pulse, blood pressure, sweating, tremor, and temperature C Perceptual disturbances These may be visual, tactile, or, more rarely, auditory. Visual disturbances range from vivid dreams to illusions (misperceiving objects in the environment), to frank hallucinations (seeing objects that are not present). Tactile disturbances (formication, the sensation of things crawling on the skin) are not rare. C Cognitive changes ranging from anxiety to paranoia, and delirium
Management Management of dependence/harmful drinking The medical practitioner’s role is to identify, monitor and give feedback on alcohol use and health consequences in their patients. Such brief intervention has been ranked as the most effective of all treatments for drinking problems.8 In the UK, all health professionals are advised to implement early identification and brief advice (IBA), using presentation for healthcare as a ‘teachable moment’. Clinicians should link their presentation to the patient’s alcohol use and offer a 20e40-min consultation with an alcohol specialist nurse.9 Follow-up monitoring by GPs or other services is also important. Screening using GGT to identify heavy drinkers, then monitoring GGT concentration and providing patients with feedback, has been shown to produce short-term differences in drinking and hospitalization, and long-term reduction in deaths due to alcoholrelated causes.10
MEDICINE 40:12
In addition, alcohol withdrawal is characterized by insomnia, and gastrointestinal disturbances (nausea and vomiting). Seizures may occur early in the course of alcohol withdrawal Table 2
638
Crown Copyright Ó 2012 Published by Elsevier Ltd. All rights reserved.
ALCOHOL AND OTHER DRUG DISORDERS
2 Babor TF, Caetano R, Casswell S, et al. Alcohol: no ordinary commoditydresearch and public policy. Oxford: Oxford University Press, 2003. 3 Gunzerath L, Hewitt BG, Li TK, Warren KR. Alcohol research: past, present, and future. Ann New York Acad Sci 2011; 1216: 1e23. 4 Dawson DA, Grant BF, Stinson FS, et al. Recovery from DSM-IV alcohol dependence: United States, 2001e2002. Addiction 2005; 100: 281e92. 5 Shuckitt M. Alcohol use disorders. Lancet 2009; 373: 492e501. 6 Conigrave KM, Degenhardt LJ, Whitfi eld JB, et al. CDT, GGT, and AST as markers of alcohol use: the WHO/ISBRA collaborative project. Alcohol Clin Exp Res 2002; 26: 332e9. 7 Saunders JB, Aaasland OG, Babor TF, de la Fuente JR, Grant M. Development of the Alcohol Use Disorders Identification Test (AUDIT): WHO collaborative project on early detection of persons with harmful alcohol consumption. Addiction 1993; 88: 791e804. 8 Miller WR, Wilbourne PL. Mesa Grande: a methodological analysis of clinical trials of treatments for alcohol use disorders. Addiction 2002; 97: 265e77. 9 NICE. Alcohol use disorders: diagnosis and clinical management of alcohol-related physical complications, www.nice.org.uk/guidance/ CG100; 2010. 10 Kristenson H, Sterling A, Nilsson J, Lindg€arde F. Prevention of alcoholrelated deaths in middle-aged heavy drinkers. Alcohol Clin Exp Resl 2002; 26: 478e84. 11 Lingford-Hughes A, Welch S, Nutt D. Evidence-based guidelines for the pharmacological management of substance misuse. Addict Comorbidity: Recommendations Br Assoc Psychopharmacol J Psychopharmacol 2004; 18: 293. 12 Shaw JM. Development of optimal treatment tactics for alcohol withdrawal. I: assessment and effectiveness of supportive care. J Clin Psychopharmacol 1981; 1: 382e7. 13 Saunders JB. Drug treatment in alcoholism. In: Burrow GD, Norman TR, eds. Drugs in Psychiatry, vol. 4. Amsterdam: Elsevier, 1987; 343e369. 14 Sechi G, Serra A. Wernicke’s encephalopathy: new clinical settings and recent advances in diagnosis and management. Lancet Neurol 2007; 6: 442e55. 15 American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th edn. Washington: DC, text revision, 2000.
patients. In Western societies, WeKS is usually observed in heavy drinkers, and autopsy studies indicate that the diagnosis was missed in 75 e80% of cases. About 80% of patients with Wernicke’s encephalopathy who survive develop Korsakoff’s syndrome, a disabling disorder characterized by severe memory defects. WeKS is a medical emergency, and doses of thiamine between 100 mg and 250 mg per day apparently may not restore central nervous system vitamin status or improve clinical signs.14 Patients who have signs indicative of Wernicke’s encephalopathy should be treated empirically with high-dose parenteral thiamine given three times daily for 2e3 days.
Prognosis and explanation People with alcohol-related disease should be advised that their prognosis depends on ceasing or reducing drinking. Most clinicians recommend long-term abstinence for dependent drinkers, due to the risk of relapse and rapid re-instatement of dependent drinking. However, in patients not willing to consider this, reducing levels of alcohol consumption may also produce significant health benefits.
Follow-up Whether with hospital services, local specialist services, or with the GP, follow-up should be offered to all patients with alcohol dependence or alcohol-related disease. People identified as drinking above safe levels should be reviewed by their GP.
Prevention Doctors should offer prophylactic parenteral thiamine followed by oral thiamine to harmful or dependent drinkers: if they are malnourished or at risk of malnourishment or they have decompensated liver disease and in addition they attend an emergency department or are admitted to hospital with an acute illness or injury.9
A REFERENCES 1 NICE. NICE clinical guideline 115 alcohol-use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence, www.nice.org.uk/guidance/CG115; 2011.
Practice points Task C Identification
Action Alcohol history, diagnosis, screening questions (e.g. AUDIT)
Knowledge Alcohol content of drinks, alcohol-related disease, biological markers
Skill Sensitive to stigma, preserve privacy and dignity
C
Prevent complications
Prophylactic thiamine, monitor withdrawal manage withdrawal Manage WeKS
Signs and symptoms of withdrawal, WernickeeKorsakoff
Vigilance regarding risk, use of withdrawal scales (e.g. CIWA) Differential diagnosis
C
Provide advice and arrange FU
Give feedback on health risks, prognosis. Refer for specialist follow up
Recommended levels of drinking Local referral agencies
Judgemental or critical responses are often counterproductive
MEDICINE 40:12
639
Crown Copyright Ó 2012 Published by Elsevier Ltd. All rights reserved.