Alcohol misuse Management in Primary Care

1. Alcohol misuse Management in Primary Care C/O www.bradfordvts.co.uk

2. Objectives Improve confidence in Detection Assessment Management of problem drinking

3. Detection 1 When to ask? Opportunistically New patient check Health check Lifestyle questionnaire When suspicion raised Physical problems Mental health problems Social problems

4. Detection 2 Who should ask? Doctors Nurses Health care assistants Receptionists Implications for training Whole team alcohol aware

5. Detection 3 What to ask? Simple questions about drinking How many days a week do you drink alcohol? How many drinks do you have on a typical day when you are drinking? Screening questionnaire e.g. CAGE Quick Validated Combination of questions will detect hazardous drinking

6. Assessment 1 - the foundations Be clear about units Be clear about sensible drinking Man: 3-4 units a day Woman: 2-3 units a day Pregnancy: alcohol not advised No binge drinking (>1/2 recommended weekly units in 1 session) 48hrs alcohol free after any binge

8. Assessment 2 - definitions Hazardous drinking Regularly drinking >5 units / day (man) or >3 units / day (woman) Risk of damage to physical or mental health Doubles man’s risk of liver disease, hypertension, some cancers, violent death

9. Assessment 3 - definitions Harmful drinking Damage caused to physical or mental health of drinker Diagnosis from history, examination and investigation

10. Assessment 4 - definitions Alcohol dependence Suspect in men drinking >50 units a week, women drinking >35 units a week 3 or more of these features Strong desire or compulsion to drink Difficulty controlling drinking (starting, stopping, quantities) Withdrawal symptoms / relief drinking Tolerance Alcohol use “taking over” Persisting use despite awareness of harmful consequences

11. What to do next?

12. The alcohol pyramid 79.1% low risk 16.3% hazardous drinkers 4.1% harmful drinkers 0.5% dependent drinkers Main primary care focus - the 20% hazardous and harmful drinkers Change more likely Bigger overall impact

13. Management 1Minimal Intervention Focus - hazardous drinkers Give clear information about Sensible drinking Hazardous / harmful drinking Emphasize by giving written information Quick - 2mins Can be done by all PHCT with training

14. Management 2 Brief intervention Focus - hazardous or harmful drinkers Give clear information about sensible drinking Explore motivation for change Set goals and discuss how they will be achieved ? Arrange follow up Can be done by doctors and nurses

15. Management 3 - counselling and other more intensive input Focus - harmful or dependent drinkers Motivational interviewing Drug treatment Harm minimisation Detoxification More time consuming, regular follow-up needed ? role for developing Enhanced Service

16. Drug treatment Detox regime Chlordiazepoxide 20mg qds, reduce by 10mg daily Vitamin supplements Thiamine 100mg x1-3 daily Vit B Co Strong 3 daily Folic acid / Ascorbic Acid Acamprosate Disulfiram

17. Referral to Alcohol Services 1 Refer to local community alcohol services When the patient asks for additional help When the patient is having problems cutting down When the patient is alcohol dependent To enhance motivation for change For counselling to explore drinking and related issues

18. Referral to Alcohol Services 2 Refer to the Community Drug & Alcohol Team When the patient is alcohol dependent and is not suitable for primary care treatment Pregnancy Significant mental health problems Drug misuse History of withdrawal fits or DTs - inpatient detox needed Previous failed attempts Difficult social circumstances e.g. poor support, homeless Too complex for resources of Primary Health Care Team The team has psychiatrist and community psychiatric nurse support with beds available in hospital

19. Referral to Alcohol Services 4 Alcoholics Anonymous Regular self-help group support Community Alcohol Support Team Practical social support for individuals or families

20. Useful resources • Drinkline - National Alcohol Helpline • Helpline: 0800 917 8282 Monday - Friday, 9am - 11pm , Weekends 6pm - 11pmOffers help to callers worried about their own drinking and support to the family and friends of people who are drinking. Advice to callers on where to go for help. • Alcoholics Anonymous • PO Box 1, 10 Toft Green, York, YO1 7NDHelpline: 0845 769 7555 Web: www.alcoholics-anonymous.org.ukThere are over 3000 meetings held in the UK each week with over 40,000 members. The only requirement for membership is a desire to stop drinking. • AL-Anon Family Groups • 61 Great Dover Street, London, SE1 4YFTel: 020 7403 0888 Web: www.al-anonuk.org.ukOffers support for families and friends of alcoholics whether the drinker is still drinking or not. • National Association for Children of Alcoholics • PO Box 64, Fishponds, Bristol, BS16 2UHHelpline: 0800 358 3456 Web: www.nacoa.org.ukServices include information, advice and support to children of alcoholics through its free helpline, and training to professionals who come into contact with children of alcoholics. • Know Your Units campaign • From the NHSWeb: www.units.nhs.ukAims to tell drinkers how many units are in their drinks and help them stick to their limits.