Alcohol Use

1)   Ask about patients current and past EtoH use and about family history

2)   Identify and recognise their level according NH&MRC guidelines;

3)   Use a screening questionnaire to detect dependence;

a.       CAGE  

                             i.      Have you ever felt the need to CUT down?

                             ii.     Do you get ANNOYED by criticism of your drinking?

                             iii     Do you ever feel GUILTY about your drinking?

                             iv.    Do you ever want an EYE opener?

Remember that 1 positive response indicates the need for further assessment and 2 gives a sensitivity > 85% and a specificity of about 90% for a diagnosis of alcohol abuse and/or dependence.

4)   Ask specific questions for alcohol abuse,

a.   Failure to fulfil work, school or social obligations

b.   Recurrent substance use in physically hazardous situations

c.   Recurrent legal problems related to substance use

d.   Continued use despite alcohol-related social or interpersonal problems

Or about alcohol dependence,

Tolerance

Withdrawal

Substance taken in larger quantity than intended

Persistent desire to cut down or control use

Time spent obtaining, using or recovering from alcohol use

Social, occupational or recreational tasks are sacrificed

Use continues despite physical and psychological problems

5)   Assess co-morbidities which may affect treatment

a.    Physical, social, emotional problems?

b.    Physical complications of EtoH use?

c.    Blood abnormalities?

6)   Identify treatment goals;

a.    Non-dependent: Controlled drinking if harms not severe, patient requests

b.    Dependent/ Organ damage/ Controlled drinking failed: Abstinence recommended as only 55 reach a stable pattern

7)   Stress benefits of decreased alcohol intake (e.g. FRAMES model – see below) and give drinking tips (harm minimisation approach – see below)

8)   Treatment as appropriate

a.    Brief Intervention – designed to increase motivation

                               i.   Feedback on relationship of problems/ findings to EtOH intake

                              ii.   Responsibility of change rests with patient

                             iii.   Advice to change drinking habit

                             iv.   Menu of strategies offered

                              v.   Empathy expressed

                             vi.    Self-efficacy encouraged

b.    Counselling

c.    Pharmacotherapy

                              i.       Acamprosate

1.   GABA agonist

2.   commence when abstinent

3.   Continue for 1 year

4.   Rare side-effect of diarrhoea

                              ii.      Naltrexone

1.   u-opiate receptor aantagonist

2.   once daily dose

3.   Side-effcets include nausea, headache, dizziness, dysphoria, depression, Increased LFTs

4.   Also start after abstinence

                             iii.      Withdrawal

1.   Some dependent drinkers will need to go through withdrawal. They can be supported by their LMO if there is adequate support at home and when withdrawal is likely to be mild/ moderate. If they are likely to have a severe withdrawal (previous history of such, high level of recent EtoH cosumption, presence of intercurrent disorders such as significant liver disease, pancreatitis, malnutrition or infection) they may need to be hospitalised for monitoring and diazepam therapy.

d.    Organise referral to a detox unit and adequate follow-up

9)   Physical examination looking for;

a.   Poor hygiene

b.   Malnutrition

c.   Ecchymoses

d.   Parotiditis

e.   Dupuytrons Contracture

f.    AF

g.   Dilated CCF

h.   Cerebellar Signs

i.    Peripheral neuropathy

j.    Pneumonia/ TB

k.   Signs of liver disease

l.    Impaired cognition

Light beer usually has about half the alcohol content of normal beer.