Alcohol Misuse

 

• Background

  Definitions

  • Hazardous drinking: consumption that increases the risk of harm. The stage before harmful drinking.
  • Harmful drinking: drinking that adversely affects physical or mental health.
  • Dependency: see substance misuse page.

  Epidemiology

  • 5-10% lifetime risk.
  • Commoner in men.

• Presentation

  Liver:

  • Begins with fatty liver disease and can progress to cirrhosis and liver failure.
  • However, many of those who misuse alcohol do not have detectable liver disease, and its absence is not a sign that everything's OK.

  GI:

  • Diarrhoea and vomiting.
  • PUD
  • Varices, presenting with haematemesis and/or melena.
  • Oesophageal erosions.
  • Pancreatitis
  • GI cancer.

  Neurological:

  • Memory and cognitive impairments.
  • Peripheral neuropathy.
  • Seizures
  • Falls
  • Wernicke's encephalopathy and Korsakoff's syndrome.

  Psychological:

  • Psychosis
  • Morbid jealousy e.g. delusion that their partner is unfaithful.
  • Alcoholic hallucinosis. In chronic alcoholism, the hallucinations are auditory, while in withdrawal they are often visual or tactile.

  CV:

  • Arrhythmia
  • HTN
  • Cardiomyopathy

  Others:

  • Anaemia
  • Osteoporosis
  • ↓Fertility
  • Breast cancer.
  • Accidents
  • Social problems.

• Investigations

  Initial identification:

  • Screen as part of routine care, as many with alcohol misuse may not actively seek help (due to stigma and nature of addiction).
  • Consider using tool such as CAGE.

  Further assessment:

  • AUDIT (Alcohol Use Disorders Identification Test) to assess pattern and severity. Proceed to following steps if >15.
  • SADQ (Severity of Alcohol Dependence Questionnaire) to assess severity.
  • APQ (Alcohol Problems Questionnaire) to assess secondary problems.
  • Detailed consumption history, both current and historical: typical day, frequency, and volume.
  • Detailed assessment of physical and psychiatric problems.

  Investigations if health problems suspected:

  • FBC: macrocytic anaemia.
  • LFT: ↑GGT, ↑↑AST, ↑ALT.
  • Offer transient elastography (FibroScan) to diagnose cirrhosis in all persistent heavy drinkers.

• Management

  Overview:

  • Management takes place within specialist alcohol services.
  • Determine where you are first with motivational interviewing. Decide on whether harm reduction or abstinence is the goal, encouraging the latter.
  • Monitor closely for the various physical health consequences of long-term dependency.

  Assisted withdrawal (aka detoxification)

  • Should be offered if drinking >15 units/day or AUDIT >20.
  • A combination of drug therapy and individual, group, and self-help psychotherapy.
  • 3 weeks of community-based treatment for most. 2-4 meetings per week in moderate dependence, or intensive day programmes for most of the week in severe dependence.
  • Inpatient or residential care is for those who drink >30 units/day, have significant psychiatric or cognitive co-morbidities, and/or have a history of epilepsy or withdrawal seizures.

  Biological

  During withdrawal:

  • Benzodiazepine – chlordiazepoxide or diazepam – titrated to severity. If community-based, monitor every 2 days and prescribe treatment for that duration.
  • Thiamine to prevent neurological complications.

  Maintenance:

  • Acamprosate or naltrexone for relapse prevention after withdrawal is completed. Acamprosate is a GABA agonist and glutamate antagonist which reduces craving. Naltrexone is an opioid receptor blocker which reduces pleasure; side effects include nausea, anorexia, fatigue, and headaches; it should not be used alongside opioids.
  • Disulfiram if acamprosate or naltrexone are not suitable. Nalmefene, an opioid receptor blocker, is another option.
  • Continue medication for at least 6 months, but stop if drinking persists for 4 weeks after starting.
  • Do baseline U&E and LFT before starting acamprosate, naltrexone, or disulfiram.

  Psychological

  Psychological treatment can be offered alone for mild dependence, or combined with pharmacotherapy for withdrawal and relapse prevention. Options include:

  • Psychoeducation for patients and carers.
  • Motivational interviewing.
  • CBT: individual, group, or behavioural couples therapy. Weekly sessions for 12 weeks.
  • Community support and self-help e.g. AA.

  Social

  • Involve families in care, in negotiation with the patient. Offer a carer's assessment, as well as guided self-help and support groups for families.
  • Will need to contact DVLA if they drive, and are unlikely to be allowed to drive until alcohol-free for 1 year.
  • Think about any safeguarding issues e.g. child neglect, domestic abuse.
  • 3 months residential rehabilitation should be offered to those who are homeless. Try to find long-term housing before discharge.

• Prognosis

  Relapse risk after stopping:

  • Very common, particularly in more severe dependency.
  • However, even episodes of abstinence can provide health benefit so are still desirable.

  5 year survival if cirrhosis is present:

  • 50% if they continue to drink.
  • 75% if they stop.

• Disulfiram

  Mechanism

  • Alcohol is initially converted to acetaldehyde by alcohol dehydrogenase.
  • Disulfiram prevents the subsequent conversion of the toxic acetaldehyde to the harmless acetic acid, by inhibiting aldehyde dehydrogenase.
  • Acetaldehyde causes hangover like symptoms around 10 minutes after drinking, which persist for about an hour.

  Effects

  • Headache and blurring of vision.
  • Nausea and vomiting.
  • Chest pain.
  • Anxiety and confusion.
  • Sweating

  Contraindications and interactions

  • Severe cardiac disease.
  • Pregnancy
  • Psychosis
  • Metronidazole. Also inhibits aldehyde dehydrogenase, which is why it can't be taken with alcohol.

• Alcohol withdrawal

  Signs and symptoms

  • Typically begin 6-24 hours after last drink.
  • Physical: tremor, sweats, nausea.
  • Psychological: insomnia, altered mood, alcoholic hallucinosis.

  Alcohol withdrawal seizures

  • Generalized tonic-clonic seizures.
  • 12-48 hours after last drink.

  Alcoholic hallucinosis

  • Hallucinations: auditory (e.g. hostile voices), visual (e.g. Lilliputian – things and people seem tiny), tactile (e.g. formication – insects crawling on/under skin).
  • May also have headaches, dizziness, and irritability.
  • 12-24 hours after last drink, resolving by 48 hours.

  Delirium tremens

  • 3-7 days after last drink.
  • Delirium, confusion.
  • Tremor and seizures.
  • ↑HR and ↓BP.

  Management

  • ABC, including fluids.
  • Monitor symptoms with CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol Scale): severe is ≥20.
  • Benzodiazepines PO for seizures and sedation. Chlordiazepoxide or diazepam is 1st line, or oxazepam if there is liver impairment. Lorazepam IV if seizures are ongoing. Barbiturates and ITU if refractory.
  • Nutritional support: thiamine, folate, and correction of any deficiencies in glucose, K+, Mg2+, and PO43-. Consider IV initially as GI absorption impaired.

• Wernicke's encephalopathy and Korsakoff's syndrome

  Pathophysiology

  • Neurological syndromes caused by thiamine (vit B1) deficiency.
  • Alcohol misuse results in reduced thiamine intake from poor nutrition and impaired GI absorption.

  Wernicke's encephalopathy

  Acute presentation, which may be mistaken for intoxication.

  Classic triad (though usually not all are present):

  • Ophthalmoplegia: nystagmus, lateral rectus palsy.
  • Ataxia with wide-gait.
  • Confusion

  Korsakoff's syndrome

  • Chronic manifestation of thiamine deficiency.
  • Anterograde amnesia: can't form new memories.
  • Retrograde amnesia: can't remember the past.
  • Confabulation: false memories – believed to be true – to fill the memory blanks.

  Management

  • Thiamine replacement: initially IM or IV as an inpatient, then PO long-term.
  • If glucose is given to correct hypoglycaemia in a chronic alcohol user, thiamine must be given concurrently as glucose will deplete remaining thiamine.