Alcohol Dependence: Approach To Detection And Treatment

23.4.07

Definitions
1. Hazardous drinker: heavy/binge drinkers with drinking patterns that pose considerable risks to their own and others' health.
2. Harmful drinker: clear evidence that alcohol use is responsible for (or substantially contributes to) physical/psychological harm - may lead to disability or have adverse consequences for interpersonal relationships.
3. Dependent drinker:
-SADQ.
-DMS IV-R.
-ICD-10 - used in all hospital admissions.
-?AUDIT.

Reasons for detecting alcohol dependence
• Failure to detect may lead to:
-Unnecessary investigations.
-Alcohol withdrawal syndrome.
-Recurrent harm (end-organ damage).
-Recurrent hospital attendance.
• Liver deaths have increased eight-fold in 3- years.
• 50% subjects die before they have a chance to stop drinking.
• Prevention of unexpected alcohol withdrawal.

Methods of detection
• History and examination.
• Clinical investigations.
• Screening/assessment questionnaires.

History and examination
• Clinical findings often completely normal.
• Clinical findings poor as early indicators of alcohol - WHO, 1987.

Clinical investigations - laboratory markers
• Blood/urine/breath alcohol:
-No information regarding severity.
-Objective evidence of recent drinking.
-Low sensitivity.
• Serum gamma glutamyl transferase (GGT).
• MCV.
• Carbohydrate-deficient transferring (CDT).
• Conventional lab tests of no use for detecting alcohol abuse/dependence. Also, %CDT cannot be used as screening instrument - Br J Gen Pract 2001 Mar.
• Lab tests useless as screening tools with sensitivities between 10% (%CDT) and 52% (GGT) - Acta Clin Belg 2002 Sep-Oct.

Screening questionnaires
• Paddington Alcohol Test (PAT):
-Staged approach.
-1 min to complete.
-A+E departments.
-Detect hazardous and harmful drinkers.
-46% of detected and referred patients re-attend.
-Constant audit and feedback improves use.

PAT staged approach
• Fall.
• Assault.
• Psychiatric.
• Repeat attender.
• Collapse.
• GI.
• Cardiac.
• Head injury.
• Unwell.
• Self-neglect.

Triggers - AAFs
• Gastritis.
• Hypertension.
• Depression.
• Stroke.
• TB.
• DM.
• Falls.

FAST alcohol screening test
• Staged approach.
• 1 min to complete.
• Sensitivity of 91%.
• Used in wide variety of settings, mainly research.

CAGE questionnaire
• 4 questions.
• More sensitive than routine lab markers.
• Insensitive to milder alcohol abuse.

Alcohol use disorders
• 10-item questionnaire.
• 10 min to complete.
• Score >8 highest sensitivity.
• Identifies hazardous drinking earlier and with greater sensitivity than:
-FAST/CAGE questionnaires.
-Routine history taking.

Screening questionnaire
• Drinking risky amounts was common (17%) in medical inpatients. Most drinkers of risky amounts had dependent (77%), but not the broad spectrum of unhealthy alcohol use anticipated.
• AUDIT reliable tool in detecting dependency.
• AUDIT cut-off of >16-19.

Assessing dependence
• DSM IV.
• ICD-10.
• Severity of alcohol dependence questionnaire (SADQ).

Assessing withdrawal
• Alcohol withdrawal symptom checklist:
-Nervousness.
-Sweating.
-Tremor.
-Nausea.
-Vomiting.
-Abdo pain.
-Seizures.
-Poor appetite.
-Hallucinations.
-Irritation.
-Confusion.
-Chill.
-Headache.
-Craving etc.

Risk factors for progression to severe withdrawal
• High alcohol intake.
• High levels of anxiety.
• Sweating (palms).
• History of severe withdrawal including seizures/delirium tremens.
• Hypoglycaemia.
• Insomnia.
• Concomitant use of other psychotropic drugs.
• Hypokalaemia.
• Tachycardia etc.

Aim for treatment
• Give support and advice for detox.
• Deliver brief interventions.
• Develop and maintain timely, effective, safe interventions.
• Train/support contemporaneous treatment.
• Referral to specialist services.
• Liaison with GPs.

Drugs of choice
• Chlordiazepoxide.
-Oxazapam if liver damage.
• Thiamine - oral/parenteral.

AWS - stages
Usual time from stopping drinking to onset Most common features
Stage 1 6-8 hours Autonomic hyperactivity, manifest in sweating, anxiety and tremor. Tremor and anxiety.
Stage 2 10-30 hours Neural excitation, including hallucinations, hyperactivity and insomnia.
Stage 3 36-70 hours Grand mal seizures
Stage 4 36-70 hours Progression to delirium tremens