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Frequently Asked Questions:

Alcohol services

Are there specifications for what a good Alcohol Care Team looks like?

The NHS Long Term Plan sets out the guidelines for an optimal ACT in their Core Service Descriptors document, which can be found at the link below:

https://www.longtermplan.nhs.uk/wp-content/uploads/2019/11/ACT-core-service-descriptor-051119.pdf

It covers aims of an optimal ACT, core service components, staffing, key operating principles, establishing the ACT within the local alcohol harm reduction system and measurement metrics.

What national guidance is there to screen for alcohol use?

In the documentation in relation to the CQUIN 9 (Preventing ill health by risky behaviours),1 Public Health England state that by implementing this CQUIN, which consists of screening and offering brief interventions for alcohol, you have the opportunity to reduce future hospital admissions and improve chronic disease management such as hypertension due to inpatient identification of risky drinking. It states that the estimated net savings are impressive at £27 per patient receiving alcohol brief advice (each year over four years). The interventions are quick, achievable and proven to be effective.

By not screening, patients may be missed going into withdrawal with the obvious risks that entails both to the patient and to the trust (both in terms of resource implications and impact on staff and other patients).

References: 1. Public Health England. The National CQUIN scheme 2017-2019.  No.9: Preventing ill health by risky behaviours – alcohol and tobacco.

What are the different ways in which people can be screened for alcohol use?

There are a number of different screening tests that can be used to assess alcohol use, but some of the most common (which are also recommended by Public Health England) are:1

  • AUDIT-C: A simple three question screening tool used to assess a person’s alcohol intake. (These three questions are also the first three questions from the AUDIT screening test detailed below.) The results help identify those individuals who may be drinking at a harmful level or those at an increasing risk of drinking at harmful levels. For more information on AUDIT-C, please click here
  • AUDIT: A comprehensive 10 question screening test that can be used to assess and identify a person’s alcohol consumption, drinking behaviours, and alcohol-related problems. The AUDIT screening test is sometimes used after the AUDIT-C test, when the score is five or more and a complete assessment is required.
  • FAST: (Fast Alcohol Screening Test) is a simple four question screening tool used to assess a person’s alcohol intake. The results help identify those individuals who may be drinking at a harmful level or those at an increasing risk of drinking at harmful levels. For more information on FAST, please click here

Reference: 1. Guidance Alcohol use screening tests, Gov.uk. https://www.gov.uk/government/publications/alcohol-use-screening-tests Last accessed Sept 2020.

What does AUDIT C stand for?

The Alcohol Use Disorders Identification Test Consumption (AUDIT-C).1 For more information on AUDIT-C, please click here.

Reference: 1. Guidance Alcohol use screening tests, Gov.uk. https://www.gov.uk/government/publications/alcohol-use-screening-tests Last accessed Sept 2020.

Which is better: AUDIT-C or AUDIT to screen for alcohol use?

The AUDIT (Alcohol Use Disorders Identification Test) is a 10-item questionnaire developed by the WHO to identify hazardous and harmful alcohol use in a clinical setting to allow for a brief intervention by clinical staff. There are numerous studies to show its validity and reliability in the detection of risky drinking.1

The AUDIT-C includes only the three questions from the full AUDIT based around alcohol consumption. Its performance as a screening test has also been evaluated by several studies and generally it has been proven to be as effective as the full AUDIT.1

The simplicity of the AUDIT-C and the speed in which it can be completed supports its routine use by GPs in primary care and in other settings where speed is of importance. The full AUDIT can then be used to make decisions about referral for specialist help for alcohol dependence if required.1

References: 1. Gual, et al. Alcohol and Alcoholism 2002; 37 (6): 591-596.

 

Alcohol misuse

What is alcohol withdrawal?

Alcohol withdrawal occurs when an individual suddenly stops drinking after heavy and/or prolonged alcohol use.1-3

As alcohol alters the balance of inhibitory and excitatory neurotransmitters, when alcohol is abruptly halted, this can cause excessive neuronal activity and cause alcohol withdrawal symptoms to develop.4,5

Patients at a higher risk of developing more severe complications include those who have:5

  • Extreme alcohol dependence
  • Higher levels of alcohol intake
  • Prolonged period of alcoholism
  • Abnormal liver function
  • Previous detoxification
  • Previous experience of seizures or delirium tremens
  • Intense craving for alcohol
  • Concomitant acute illness
  • Older age
  • Use of other drugs in addition to alcohol

References: 1. Alcohol Withdrawal, Alcohol rehab guide. https://www.alcoholrehabguide.org/alcohol/withdrawal/ Last accessed Sept 2020. 2. What is alcohol withdrawal? WebMD. https://www.webmd.com/mental-health/addiction/alcohol-withdrawal-symptoms-treatments#1 Last accessed Sept 2020. 3. Mayo-Smith M.F, et al. Arch Intern Med. 2004;164(13):1405-1412. 4. Bayard, M, et al. Am Fam Physician. 2004; 15;69(6):1443-1450. 5. Saitz, R. Alcohol Health Res World. 1998; 22(1): 5-12.

What are the signs of alcohol withdrawal?

Alcohol withdrawal symptoms can vary from minor symptoms such as insomnia and tremulousness to more severe complications such as withdrawal seizures, delirium tremens and death.1,2

If alcohol intake has stopped suddenly, then two or more of the below (within several hours to a few days) can be a sign of alcohol withdrawal:1

  • Autonomic hyperactivity (e.g., sweating or pulse rate greater than 100 beats per minute)
  • Increased hand tremor
  • Insomnia
  • Nausea or vomiting
  • Transient visual, tactile, or auditory hallucination s or illusions
  • Psychomotor agitation
  • Anxiety
  • Grand mal seizures

References: 1. Bayard, M, et al. Am Fam Physician. 2004; 15;69(6):1443-1450. 2. Alcohol dependence, British National Formulary. https://bnf.nice.org.uk/treatment-summary/alcohol-dependence.html Last accessed Sept 2020.

How do you identify alcohol withdrawal?

Symptoms of alcohol withdrawal syndrome (AWS) may develop after the abrupt discontinuation or decrease of alcohol consumption. Symptoms can vary from autonomic hyperactivity and agitation to delirium tremens.1

AWS represents a clinical condition characterized by symptoms such as agitation, tremors, irritability, anxiety, hyperreflexia, confusion, hypertension, tachycardia, fever and diaphoresis. AWS usually develops in alcohol-dependent patients within 6–24 hours after the abrupt discontinuation or decrease of alcohol consumption. It is a potentially life-threatening condition whose severity ranges from mild/moderate forms characterized by tremors, nausea, anxiety, and depression, to severe forms characterized by hallucinations, seizures, delirium tremens and coma.

The mild-moderate form of AWS is often self-managed by patients or disappears within 2–7 days from the last drink, while more severe AWS requires medical treatment, often with benzodiazepines. The identification and subsequent treatment of AWS is of paramount clinical importance, given that AWS is one of the causes of preventable morbidity and mortality.

References: 1. Mirijello A et al. Identification and management of alcohol withdrawal syndrome. Drugs 2015 March;75(4): 353–365

 

Alcohol related conditions

What is Wernicke’s encephalopathy, what are the symptoms, how is it diagnosed and how common is it?

Wernicke’s encephalopathy (WE) is an acute neurological disorder caused by thiamine deficiency.1   Symptoms can include:

  • Dietary deficiencies – significant weight loss over a short period of time, poor diet, or evidence of malnourishment
  • Eye signs – ophthalmoplegia, nystagmus, or gaze palsy
  • Cerebellar dysfunction – ataxia, abnormal past pointing, or dysdiadochokinesia
  • Altered mental state or mild memory impairment – disorientation, confusion

Using Caine’s criteria, a patient is diagnosed with WE when they demonstrate two of the four signs above.2 Of those people who misuse alcohol, post mortem studies have shown that Wernicke’s encephalopathy may occur in as many as 12.5%.3

References: 1. Thomson AD, Marshall EJ. The natural history and pathophysiology of Wernicke’s encephalopathy and Korsakoff’s psychosis. Alcohol Alcohol 2006; 41: 151–158. 2. Caine D, Halliday G, Kril J, Harper C. Operational criteria for the classification of chronic alcoholics: identification of Wernicke’s encephalopathy. J Neurol Neurosurg Psychiatry 1997; 62 (1): 51–60  3. National Institute for Health and Care and Excellence. June 2010. (updated April 2017). Alcohol use disorders and clinical management of alcohol-related physical complications [Clinical Guidance 100].

What is Korsakoff’s psychosis, what are the symptoms and how common is it?

Korsakoff’s psychosis (KP) can occur following inadequately treated WE.1 It is chiefly a memory disorder, in particular loss of episodic memory1,2

Working (recent) memory is generally impaired and people with KP are typically unable to remember incidents or episodes from their past, they may also have difficulty in learning new facts, concepts and language. Confabulation may also occur in KP.1 This may be the unprovoked outpouring of erroneous memories, i.e. events that have not happened, or memory distortions.

Without adequate treatment, up to 84% of patients with WE are found to develop Korsakoff’s psychosis when followed up long-term.3

References: 1. Kopelman MD, Thompson AD, Guerrini I, et al. The Korsakoff syndrome: clinical aspects, psychology and treatment. Alcohol Alcohol 2009; 44:148–154. 2. Smith I, Hillman A. Management of alcohol Korsakoff syndrome. Adv Psychiatr Treat 1999; 5: 271–278. 3. Thomson AD, Cook CCH, Touquet R, Henry JA. The Royal College of Physicians report on alcohol: guidelines for managing Wernicke’s encepaholpathy in the Accident and Emergency department. Alcohol Alcohol 2002; 37: 513–521.

What is alcohol related liver disease?

Alcohol related liver disease is when hepatic lesions develop due to prolonged and heavy alcohol consumption.1,2

There are three main stages of alcohol related liver disease, although there’s often an overlap between each stage.2,3

1: Steatosis/Alcoholic fatty liver disease

The first stage of alcohol related liver disease is steatosis which is the most common response to high alcohol intake levels and develops in more than 90% of individuals who drink 4-5 standard drinks per day over decades.

Fatty liver disease rarely causes any symptoms, but it’s an important warning sign that drinking is at a harmful level. It is also reversible, with the liver returning to normal after 2 weeks of abstinence.

2: Alcoholic hepatitis

Alcoholic hepatitis is a more severe condition that can be caused by alcohol misuse over a more prolonged period. Liver injury is characterised by swollen, dying hepatocytes, neutrophilic infiltration, and the development of tangled aggregates of insoluble proteins.

Less commonly, alcoholic hepatitis can occur if shorter binge periods of drinking occur.

The damage associated with mild alcoholic hepatitis is often reversible if drinking is stopped permanently. However severe alcoholic hepatitis, can be serious and life-threatening

3: Cirrhosis

Cirrhosis is the late stage of hepatic scarring and is generally not reversible. The World Health Organization’s Global Status Report on Alcohol and Health estimated that 50% of all deaths caused by cirrhosis were due to alcohol.

A patient with alcohol-related cirrhosis who doesn’t stop drinking has less than 50% chance of living for at least 5 more years.

References: 1. Alcohol-related liver disease, Drinkaware. https://www.drinkaware.co.uk/facts/health-effects-of-alcohol/alcohol-related-diseases/alcohol-related-liver-disease Last accessed Sept 2020. 2. Osna, NA, et al. Alcohol Res. 2017; 38(2): 147–161. 3. Alcohol-related liver disease, NHS Inform. https://www.nhsinform.scot/illnesses-and-conditions/stomach-liver-and-gastrointestinal-tract/alcohol-related-liver-disease Last accessed Sept 2020.

What are the first signs of liver damage from alcohol?

Alcohol related liver disease often does not cause any symptoms until the liver has been severely damaged.1 At this stage, symptoms can include:1

  • Nausea
  • Weight loss
  • Loss of appetite
  • Jaundice
  • Swelling in the ankles and abdomen
  • Confusion or drowsiness
  • Blood in vomit or stools

Often alcohol related liver disease is diagnosed during tests for other conditions, or at an advanced stage of liver damage.

Reference: 1. Alcohol-related liver disease, NHS Inform. https://www.nhsinform.scot/illnesses-and-conditions/stomach-liver-and-gastrointestinal-tract/alcohol-related-liver-disease Last accessed Sept 2020.

Treatment of Wernicke’s encephalopathy

What are the national guidelines for the treatment of Wernicke’s encephalopathy?

NICE guidance recommends parenteral thiamine for Wernicke’s encephalopathy (WE). Keep a high level of suspicion for Wernicke’s encephalopathy and treat for a minimum of 5 days, unless WE is excluded, if the patient is:1

  • malnourished /at risk of malnourishment or has decompensated liver disease

AND

  • has attended an emergency department or has been admitted to hospital with an acute illness or injury.

Patients should be treated at the upper end of the BNF dose range.1

BNF recommends for the treatment of suspected or established Wernicke’s encephalopathy: Pabrinex (vitamins B & C) IV, 2-3 pairs of ampoules, 3 times a day, for 3–5 days, followed by 1 pair, once daily, for a further 3-5 days or for as long as improvement continues.2

The Royal College of Emergency Medicine (RCEM) toolkit recommends parenteral thiamine in: suspected Wernicke’s encephalopathy; the intoxicated; those with symptoms that could mask WE; or, those at risk of WE. In the Emergency Department, infuse Pabrinex IV 2 pairs at once; then on transfer to CDU, infuse 2 pairs 3 times a day. In those at high risk likely to be referred onward, infuse 2 pairs 3 times a day for 5 days.3

The British Society of Gastroenterology recommends that patients with decompensated liver disease and a history of alcohol should be administered Pabrinex IV.4

References: 1. National Institute for Health and Care and Excellence. Full Guidance June 2010. (updated April 2017). Alcohol use disorders and clinical management of alcohol-related physical complications [Clinical Guidance 100]. 2. Vitamin B substances with ascorbic acid, British National Formulary. https://bnf.nice.org.uk/drug/vitamin-b-substances-with-ascorbic-acid. html Last accessed April 2020. 3. Royal College of Emergency Medicine. Alcohol: A toolkit for improving care. June 2015. 4. British Society of Gastroenterology. Decompensated Cirrhosis Care Bundle – First 24 Hours. Available at: https://www.bsg.org.uk/resource/bsg-basl-decompensated-cirrhosis-care-bundle.html  Last accessed April 2020.

What are the benefits of giving parenteral thiamine over oral thiamine?

The high blood concentrations required to reverse Wernicke’s encephalopathy (WE) cannot be met by oral thiamine alone.1 Degree of malnutrition, alcohol consumption, and extent of liver damage independently compounds thiamine depletion.1 In the malnourished alcoholic, thiamine blood concentrations can fall to between 30-80%.2

Absorption in a dose of oral thiamine > 15mg in the healthy is no greater than 4.5mg–5.6mg. This depletes by more than three times to < 1.5mg for the malnourished abstinent alcoholic, or less when intoxicated. In a person with WE, concentrations obtained from oral thiamine are insufficient to restore thiamine levels to the brain to prevent further damage.1,2

In the presence of risk factors and/or signs and symptoms associated with suspected or established WE; a prompt regimen of Pabrinex IV infused at 2 pairs, 3 times a day3-5 for a minimum of 5 days,3,6 is considered the most effective treatment regimen to meet these criteria.3

References: 1. Thomson AD, Guerrini I, Marshall EJ. Wernicke’s encephalopathy: Role of Thiamine. Practical Gastroenterol. 2009;23:21-30. 2. Thomson AD and Marshall EJ. The natural history and pathophysiology of Wernicke’s encephalopathy and Korsakoff’s psychosis. Alcohol Alcohol. 2006;41(2):151-158. 3. Thomson AD, Marshall EJ, & Bell DB. Time to Act on the Inadequate Management of Wernicke’s Encephalopathy in the UK. Alcohol Alcohol. 2013;48(1):4-8. 4. Pabrinex (vitamins B & C) High Potency Concentrate Solution for Intravenous Infusion Summary of Product Characteristics. Kyowa Kirin Ltd. May 2018. 5. BNF Pabrinex online monograph – BNF Online. Pharmaceutical Press. Accessed April 2020. 6. NICE Clinical Guideline 100 – Alcohol-use disorders: Diagnosis and clinical management of alcohol-related physical complications – June 2010 (April 2017 update).

How should parenteral thiamine be given to diabetic patients?

The Royal College of Physicians recognise that all hypoglycaemic patients, irrespective of their alcohol status, who are treated with IV glucose must be given IV thiamine at the same time to avoid the risk precipitating Wernicke’s encephalopathy (WE).1

Patients with diabetes should be:

  • Monitored, (e.g. via their blood glucose levels), in accordance with their specific circumstance.
  • Managed clinically by the treating physician on an individual case by case basis. The patient’s full clinical history should also be considered.
  • Consideration should also be given to the patient’s glucose status, e.g. if the patient is hyper or hypoglycaemic.

References: 1. Thomson AD, Cook C, Touquet R, et al. The Royal College of Physicians Report on Alcohol: Guidelines for Managing Wernicke’s Encephalopathy in the Accident and Emergency Department. Alcohol Alcohol. 2002;37(6):513-521.

When should Intramuscular thiamine be considered?

In community environments, i.e. outside of the acute hospital setting, intramuscular thiamine can be used as an alternative parenteral route, in favour of thiamine intravenous infusion. The Maudsley Prescribing Guidelines for Psychiatry1 recognise that for a psychiatric inpatient setting, in those undergoing alcohol detoxification or withdrawal, the advice is to give intramuscular thiamine daily for five days. This dosing regimen is referred to as prophylaxis.

Note: Pabrinex Intramuscular High Potency (IMHP) solution for injection is indicated in adults and children for rapid therapy of severe depletion or malabsorption of the water-soluble vitamins B and C at one pair twice a day for 7 days.

Maudsley1 recommend when WE is suspected, that the patient is transferred to a medical unit where Pabrinex Intravenous High Potency (IVHP), Concentrate for Solution for Infusion can be administered, at a dose of:

  • At least 2 pairs of ampoules, 3 times a day for 3-5 days, followed by one pair once daily for a further 3-5 days or longer (until no further response is seen).

References: 1. Taylor D,Paton C,Kapur S. The Maudsley Prescribing Guidelines in Psychiatry (13th Ed.).Oxford:Wiley-Blackwell. 2018.

How should thiamine deficient patients with decompensated liver disease be managed?

High plasma concentrations of thiamine are required to reverse the effects of Wernicke’s encephalopathy (WE). In a person with WE, high concentrations of thiamine are required to restore thiamine levels to the brain to prevent further neurological damage.1,2

High concentrations of thiamine administered parenterally, of up to 250mg, have shown to be insufficient to reverse WE in all cases.1

British Society of Gastroenterology guideline recommendation for the use of intravenous thiamine in decompensated liver disease.

The British Society of Gastroenterology (BSG) states:3

  • Decompensated cirrhosis is a medical emergency with a high mortality. Effective early interventions can save lives and reduce hospital stay.
  • For decompensated liver disease (cirrhosis), if the patient has a history of current excess alcohol consumption, Pabrinex IV, at 2 pairs of ampoules, 3 times daily should be administered.
  • The first dose should be given within the first six hours of admission.

NICE recommend that unless WE is excluded, it is important to administer thiamine towards the upper end of the BNF dose range (i.e. Pabrinex (vitamins B & C) IV, infused at 2 pairs of ampoules, 3 times a day) for a minimum of 5 days.4,5

References: 1. Thomson AD, Guerrini I, Marshall EJ. Wernicke’s encephalopathy: Role of Thiamine. Practical Gastroenterol. 2009;23:21-30. 2. Thomson AD and Marshall EJ. The natural history and pathophysiology of Wernicke’s encephalopathy and Korsakoff’s psychosis. Alcohol Alcohol. 2006;41(2):151-158. 3. BSG – BASL (British Association for the Study of the Liver) Decompensated Liver Disease Care Bundle – https://www.bsg.org.uk/resource/bsg-basl-decompensated-cirrhosis-care-bundle.html – accessed Mar 2020. 4. BNF Pabrinex online monograph – BNF Online. Pharmaceutical Press. Accessed April 2020. 5. NICE Clinical Guideline 100 – Alcohol use disorders: Diagnosis and clinical management of alcohol-related physical complications – June 2010 (April 2017 update).

 

Treatment of other alcohol-related conditions

What treatment is recommended for alcohol withdrawal?

Management will be dependent on the severity of the symptoms and any other underlying health conditions. Treating withdrawal symptoms can take both a pharmacological and nonpharmacological approach.1

The BNF recommends:2

  • Patients with mild alcohol dependence: usually do not need assisted alcohol withdrawal. In harmful drinkers or patients with mild alcohol dependence, a psychological intervention (such as cognitive behavioural therapy) should be offered. In those who have not responded to psychological interventions alone or who have specifically requested a pharmacological treatment, acamprosate calcium or oral naltrexone hydrochloride can be used in combination with a psychological intervention.
  • Patients with moderate dependence: can generally be treated in a community setting unless they are at high risk of developing alcohol withdrawal seizures or delirium tremens
  • Patients with severe dependence: should undergo withdrawal in an inpatient setting. Patients with decompensated liver disease should be treated under specialist supervision.

NICE suggests the following pharmacotherapy options:3

  • Consider offering a benzodiazepine or carbamazepine.
  • Clomethiazole may be offered as an alternative to a benzodiazepine or carbamazepine. However, it should be used with caution, in inpatient settings only and according to the SPC.
  • In people with alcohol withdrawal seizures, consider offering a quick-acting benzodiazepine to reduce the likelihood of further seizures.
  • In people with delirium tremens, offer oral lorazepam as first-line treatment. If symptoms persist or oral medication is declined, offer parenteral lorazepam or haloperidol.

As many patients with alcohol withdrawal have multiple management issues (e.g. Wernicke’s encephalopathy, seizures, depression, substance abuse, liver disease, etc), they may require a coordinated, multidisciplinary approach to their treatment.4

References: 1.Saitz, R. Alcohol Health Res World. 1998; 22(1): 5-12. . 2. Alcohol dependence, British National Formulary. https://bnf.nice.org.uk/treatment-summary/alcohol-dependence.html Last accessed Sept 2020. 3. Acute alcohol withdrawal, NICE Pathways. https://pathways.nice.org.uk/pathways/alcohol-use-disorders/acute-alcohol-withdrawal#content=view-node%3Anodes-treatment Last accessed Sept 2020. 4. McKeon A, et al. Journal of Neurology, Neurosurgery & Psychiatry 2008; 79: 854-862.

What is the treatment for alcohol related liver disease?

There are currently no specific medical treatments for alcohol related liver disease. Abstinence and lifestyle modifications are the best options for resolving and reducing the risk of further damage.1,2

NICE recommendations include:3

Assessment:

  • Exclude alternative causes of liver disease in people with a history of harmful or hazardous drinking who have abnormal liver blood test results.
  • Refer people to a specialist experienced in the management of alcohol-related liver disease to confirm a clinical diagnosis of alcohol-related liver disease.
  • Consider liver biopsy for the investigation of alcohol-related liver disease.
  • In people with suspected acute alcohol-related hepatitis, consider a liver biopsy to confirm the diagnosis if the hepatitis is severe enough to require corticosteroid treatment.

Referral for consideration of liver transplantation:

  • Refer patients with decompensated liver disease to be considered for assessment for liver transplantation if they:
    • still have decompensated liver disease after best management and 3 months’ abstinence from alcohol and
    • are otherwise suitable candidates for liver transplantation.

References: 1. Alcohol-related liver disease, NHS Inform. https://www.nhsinform.scot/illnesses-and-conditions/stomach-liver-and-gastrointestinal-tract/alcohol-related-liver-disease Last accessed Sept 2020. 2. Osna, NA, et al. Alcohol Res. 2017; 38(2): 147–161. 3. National Institute for Health and Care and Excellence. Clinical Guideline June 2010. (updated April 2017). Alcohol use disorders and clinical management of alcohol-related physical complications [Clinical Guideline 100].

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