LUCY HARRISON

Alcohol CNS

Ext: 21487, bleep 6110

July 2014

1. To understand why we need to ask all patients who attend the ED about their alcohol use.

2. Who has problems with alcohol?

3. How do we ask people about their alcohol use?

4. How to detect possible dependence to alcohol?

5. How do we manage alcohol dependant patients in the ED?

6. Non dependant patients.

Alcohol costs the NHS £2.7 billion per year.

Recent reports indicate that 10.5 million adults drink above the recommended limits.

Alcohol is the 3rd leading cause of disease burden in developed countries.

There are over a million hospital admissions due to alcohol each year in England. In 2009/10 20,032 individuals in Bristol were admitted to hospital either wholly or partly due to alcohol.

WHAT SORT OF ED PRESENTATIONS COULD BE

ALCOHOL RELATED?

Fall Accident Collapse Head Injury Assault Unwell Gastro Intestinal Cardiac Psychiatric ( including OD/DSH) Repeat attendee Touquet et al

(2009)

Who has problems with alcohol?

ACCORDING TO GOOGLE:

Jonny Depp, Russell Brand, Michael J Fox, Davina McCall, David Hasselhoff, Mel Gibson, Robin Williams, Steven King, Tara Palmer-Tomkinson, Florence Welch, Kelly Osbourne, Frank Skinner, Ben Affleck, Denzel Washington, Ewan McGregor, Diana Ross, Matthew Perry, Eminem, Christina Ricci, Simon Pegg, Kate Moss, Daniel Radcliffe, Jada Pinket-Smith, Kristin Davis, Drew Barrimore, Eva Mendes, Micha Barton, Angelina Jolie, George Clooney, Sadie Frost, Katie Perry, Anne Robinson, Kirsten Dunst, Demi Moore, Charlie Sheen, Tara Reid, Oprah Winfrey, Mike Tyson, Damien Hurst, Nicole Ritchie, Winona Ryder, Cory Monteith, Jamie Lee-Curtis, Jemima French, Jim Carey, Mark Owen, Tom Chaplain, Toby Maguire, Naomi Campbell, Alex James, Gerard Butler, Gazza, Pearl Lowe, David Bowie, Shaun Ryder, Colin Farrell, Brittany Spears, Anthony Hopkins, Pete Doherty, Robbie Williams, Sarah Harding, Graham Coxon……

To be able to manage patients care safely while in the department.

To be able to offer support/ advice etc around patients’ alcohol use if they feel it is required. This can help to reduce further hospital attendances in the long run.

The ensure that patients are aware of the risks involved in regularly drinking more than the recommended amounts.

Use of the Paddington Alcohol Test (PAT).

Consists of three questions. Takes very little time to do. Anyone can complete it. Anyone who is PAT positive should be asked if they

would like to see the alcohol nurse specialist. Anyone who is PAT positive leads you to consider more

questions about a patients’ alcohol use eg, is there concern that there maybe a dependence to alcohol?

Patients who experience 3 or more of the following symptoms are likely to have alcohol dependence:

A strong desire or compulsion to drink. Difficulty in controlling levels of alcohol use. Experience of physical withdrawal on stopping alcohol

use. Increased tolerance to alcohol. Neglect of other interests eg eating or washing.

Tremor Fever Anxiety Insomnia Sweating Nausea/ vomiting Agitation/ irritability Tachycardia Hallucinations Mild systolic hypertension

Symptoms of withdrawal can be seen within 6-8 hours of the last alcoholic drink. They peak at 10-30 hours, and usually begin to stop at 30-40 hours.

DT’s only occur in around 5% of patients experiencing alcohol withdrawal, but account for a high rate of mortality. DT’s represent a medical emergency, and usually have an onset 2-3 days post the last alcoholic drink.

Symptoms of DT’s: Auditory and visual hallucinations. Confusion and disorientation Severe tremors Delusion Agitation Tachycardia Fever Hypertension

Seizures can be another symptom of alcohol withdrawal, but are rare beyond 48 hours after the last alcoholic drink. Consider admission if it is the first ever instance, otherwise base treatment on the severity of the seizure and observed recovery.

Chlordiazepoxide is used to treat alcohol withdrawal.

20-40mg of chlordiazepoxide QDS depending on level of alcohol use. Additional PRN chlordiazepoxide should be considered, up to 240mg in total can be given in a 24 hour period.

If symptoms persist, consider lorazepam or haloperidol.

(prescribing guidance for chlordiazepoxide is on the DMS)

Wernikes encephalopathy is caused by thiamine deficiency, but can be reversible if treated early. It is also very difficult to diagnose, especially if the patient is intoxicated. As there is no simple test for wernikes encephalopathy, all patients with evidence of chronic alcohol misuse should be prescribed pabrinex.

IV Pabrinex 1and 2, 2 pairs TDS.(Prescribing guidance is on DMS)

TTA chlordiazepoxide should not be prescribed to patients being discharged from the ED.

Once discharged from the ED, patients should be advised to contact their GP and offered an appointment with the alcohol nurse specialist. They should be advised to continue drinking until they have the support of specialist services to help them detox safely. They should be advised of the risks of stopping drinking suddenly. Please give out the advice leaflet on this.

Alcohol can still cause harm and be problematic even if the patient is not alcohol dependant...

They can still benefit from our advice and support.

Does alcohol have an impact on your patients health and wellbeing, is it likely to in the future?

Is alcohol stopping your patient from meeting their own basic needs?

(Maslow’s Hierarchy Of Needs)

Remember to consider the effect alcohol may be having on others too

Please refer to the drug and alcohol connect site for advice/ information and for links to alcohol related information leaflets.

There is a Smart Recovery group run by the drug and alcohol nurses every Wednesday evening (Queens building, level 4, clinic 9).