Many patients undergoing alcohol withdrawal can do so safely at home under supervision, but some need inpatient admission, writes Grozdana Lalevic

Medical, mental and behavioural problems due to alcohol use are common. Overall, 4% of the global burden of disease is attributable to alcohol, which accounts for about as much death and disability globally as tobacco and hypertension (see Figure 1).¹

Figure 1: Global distribution of all alcohol-attributable deaths by disease or injury

More than 80 deaths every month in Ireland are directly attributable to alcohol, and one in four deaths of young men aged 15-39 in Ireland are related to alcohol. Furthermore, there are 1,200 cases of cancer detected each year in Ireland related to alcohol.²

The Global Burden of Disease project showed that the proportion of Irish 15-year-olds (together with British and Danish) who had been drunk three times or more in the past 30 days considerably exceeded the proportion of 15-year-olds elsewhere in Europe.³

There is clear and conclusive evidence that the problems from consumption levels are reflected in both admissions to general hospitals and attendances at emergency departments. Hope et al suggested that 20-50% of all presentations to ED s in Ireland are alcohol-related, with the figure rising to more than 80% at peak weekend periods.⁴

How much is too much?
Hazardous drinking is consuming more than 17 standard drinks per week for men or 11 standard drinks per week for women. (A standard drink has 10g of pure alcohol.) There is an increased risk of liver disease for those who drink daily, compared with those who drink intermittently or periodically. The liver needs at least two to three alcohol-free days to recover after drinking anything but the smallest amount of alcohol.⁵

Harmful alcohol use or abuse refers to a pattern of use that is causing damage to health.⁶ The damage may be physical (eg. hepatitis) or mental (eg. depressive episodes secondary to heavy alcohol intake). Harmful use commonly, but not invariably, has adverse social consequences.

Alcohol dependence is defined as ‘cluster of physiological, behavioural and cognitive phenomena in which the use of alcohol takes on much higher priority for a given individual than other behaviours that once had greater value’.⁶

A definite diagnosis of dependence should only be made if at least three of the following have been present together in the past year: compulsion to take alcohol; difficulties controlling alcohol taking behaviour; physiological withdrawal state; evidence of tolerance; neglect of alternative interests; and/or persistent use despite harm.

Detection of alcohol misuse
The clinical assessment of alcohol misuse involves finding out the number of standard drinks consumed per week; patterns of drinking; physical and mental health of the patient; and testing blood markers. The following screening questionnaires for detection of alcohol misuse, severity and withdrawal are useful:

• CA GE, PAT, FAST – for detection of alcohol misuse, quick and easy to use in ED settings
• A UDIT – more detailed 10-question screening test suitable for primary care settings⁷ (see adapted algorithm in Table 1)
• SADQ – for severity of alcohol dependence
• CI WA Ar – for detection of alcohol withdrawal and measure of severity of withdrawal. Score > 10 indicates withdrawal.⁸

People who misuse alcohol often tend to misuse benzodiazepines or other illicit drugs, so it is always worth asking them about other substances.

Table 1: Identification and management of harmful drinking and alcohol dependence

Presentation of alcohol problems in the medical setting
Patients usually present for three major reasons:

1. Wishing to abstain from alcohol and not in alcohol withdrawal or alcohol-dependent
This group of people would have an AUDIT score < 20. The principles underlying most approaches to brief interventions were systemised by Hester and Miller in what is called the FRAMES model:⁹

• Feedback – give feedback on the risks and negative consequences of substance use. Seek the client’s reaction and listen
• Responsibility – emphasise that the individual is responsible for making his or her own decision about their drug use
• Advice – give straightforward advice on modifying drug use
• Menu of options – give menu of options to choose from, fostering the client’s involvement in decision-making
• Empathy – be empathic, respectful and non-judgmental
• Self-efficacy – express optimism that the individual can modify his or her substance use if they choose. Self-efficacy is one’s ability to produce a desired result or effect.

2. Alcohol-related medical comorbidities or injuries
This includes patients presenting with accidental or deliberate self-harm.

3. Alcohol dependent or in alcohol withdrawal
Most patients undergoing alcohol withdrawal can do so safely at home with regular supervision by their GP. For people who typically drink over 15 units per day and/or score 20 or more on AUDIT, detox in the community is a possible option. Consider inpatient detox in individuals with: severe alcohol dependence; history of delirium tremens or seizures; poor physical health; pregnancy; major mental illness; cognitive impairment; or multiple failed community detoxifications.

Alcohol withdrawal timeline example

• Six to 16 hours after last drink: tremor, headache, nausea, vomiting, anxiety, agitation, tachycardia, hypertension, insomnia
• 12-24 hours after last drink: the above plus seizures and perceptual abnormalities
• Two to five days after last drink: the above plus delirium tremens (a complication of alcohol withdrawal), involves severe agitation, confusion, hallucinations, seizures, fever.

Most of the withdrawal symptoms subside five to seven days after last drink, but craving for alcohol may persist longer.

Drugs used in acute withdrawal
Benzodiazepines are used to prevent/relieve withdrawal symptoms and to prevent delirium and seizures. Most commonly used would be diazepam and chlordiazepoxide. They do not reduce craving and after initial detox, additional interventions may be required. For examples of chlordiazepoxide detox see Table 2.¹⁰

Vitamin B complex is used for prophylaxis or treatment of Wernicke-Korsakoff’s syndrome (WKS). A presumptive diagnosis of Wernicke’s encephalopathy (WE) should be made for any patient with a history who shows one or more of the following: evidence of ophthalmoplegia, ataxia, acute confusion, memory disturbance, unexplained hypotension, hypothermia, unconsciousness or coma.

Thiamine replacement is still the critical intervention for WKS, and increased vulnerability is associated with genetic susceptibility in association with poor diet.

Recommendations for treatment of WKS and WE:¹¹

• Oral thiamine 300mg for a healthy individual with uncomplicated and low-risk ADS
• High-risk WE (unwell and malnourished) – parenteral Pabrinex one pair three to five days
• E stablished WE – parenteral Pabrinex two pairs three to five days followed by one pair three to five days or according to response.

  Table 3: Useful resources

  www.addictionireland.ie www.prioritymedicalclinic.ie www.dualdiagnosis.ie www.bushypark.ie www.stpatricks.ie www.rutlandcentre.ie www.stjohnofgodhospital.ie www.coolmine.ie www.taborlodge.ie www.probation.ie ICGP CPD Education e-learning module on alcohol awareness, http://www.icgp.ie/go/courses/

Promoting abstinence
Detoxification is usually the first step towards abstinence, followed by appropriate addiction aftercare/support (see below). The four pharmacological treatments available to maintain abstinence include:¹¹

• Acamprosate – acts as a functional glutamatergic antagonist. It is generally well tolerated; nausea and diarrhoea would be the main side-effects. It does not interact with alcohol and reduces cravings. The current recommendation is that it is to be given for one year.2 In patients with moderate renal dysfunction (creatinine clearance 30-50ml/min), the initial dose should be 333mg three times daily, but usual dosage is 666mg three times daily
• Naltrexone – acts as non-selective competitive antagonist of the opioid receptor which prevents the endogenous opioids from binding to the receptor, therefore giving reduction in the pleasurable effects from alcohol. Consequently, naltrexone reduces the alcohol’s rewarding effects and also cravings. The recommended dosage of naltrexone is 50mg per day in a single dose. NICE¹² recommends that oral acamprosate or naltrexone should be offered to those who are moderately to severely dependent or drinking harmfully if failing to improve. Both acamprosate and naltrexone should be stopped if drinking persists beyond four to six weeks, and should be considered in combination with psychological intervention
• Disulfiram – it blocks aldehyde dehydrogenase, causing accumulation of acetaldehyde if alcohol is consumed resulting in nausea, flushing and palpitations. NICE recommended that disulfiram should be tried after acamprosate or naltrexone, or where the patient indicates a preference for it. There is no evidence to guide how long to prescribe disulfiram, but clearly it can only be started once the patient is alcohol-free for at least 24 hours. Patients must also be warned about the potential for a reaction with alcohol for up to seven days after stopping disulfiram. The average maintenance dose is 250mg daily
• Baclofen – The anti-craving and anti-reward effects of baclofen appear to relate to its agonist effect on GABA-B receptors. Baclofen should be considered if a patient wants to be abstinent, has a high level of anxiety and has not benefited or is unable to take acamprosate, naltrexone or disulfiram. Start therapy at a low dosage and increase gradually until optimum effect is achieved (usually 40-80mg daily).

Grozdana Lalevic is a registrar in liaison psychiatry at Cork University Hospital

Acknowledgements
I would like to thank Dr Eugene Cassidy, consultant psychiatrist in liaison psychiatry, Cork University Hospital for his valuable and constructive suggestions, enthusiastic encouragement and useful critiques of this article.

References

1. Global status report on alcohol and health, 2004 Accessed on http://www.who.int/substance_abuse/publications/globalstatusreportalcoholchapters/en/. Accessed April 10, 2014
2. Health Research Board JB. Alcohol: Public Knowledge, Attitudes and Behaviours. Accessed on http://www.hrb.ie/uploads/tx_hrbpublications/Alcohol_-_Public_Knowledge_Attitudes_and_Behaviours_Report.pdf. Accessed March 12, 2014
3. Room R, Babor T, Rehm J. Alcohol and public health. The Lancet 2005; 365 (9458): 519-530
4. Hope et al. Alcohol and Injuries in the Accident and Emergency Department: A National perspective Internet pages. Available from: http://www.dohc.ie/publications/ pdf/alcohol_%20and_injuries.pdf?direct=1. Accessed March 22, 2014
5. Science and Technology Select Committee. Inquiry on alcohol guidelines. http:// www.rcplondon.ac.uk/sites/default/files/rcp_evidence_to_the_inquiry_on_alcohol_ guidelines_1.pdf. Accessed on April 26, 2014
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7. Babor TF, Higgins-Biddle JC, Saunders JB, Monteiro MG. The Alcohol Use Disorders Identification Test, Guidelines for Use in Primary Care. 2nd Ed. Department of Mental Health and Substance Dependence, World Health Organization
8. Cassidy EC, O’Sullivan IO, Bradshaw PB, et al. Symptom-triggered benzodiazepine therapy for alcohol withdrawal syndrome in the emergency department: a comparison with the standard fixed dose benzodiazepine regimen. Emergency Medicine J 2012; 29(10): 802-804
9. Barry JB. Towards a framework for implementing evidence based alcohol Interventions, 2012. Available from www.hse.ie
10. Taylor DT. The Maudsley Prescribing Guidelines. 10th ed. London: Informa Healthcare; 2009
11. Lingford-Hughes R, Welch S, Nutt DJ. Evidence-based guidelines for the pharmacological management of substance misuse, addiction and comorbidity: recommendations from the British Association for Psychopharmacology. J Psychopharmacol. 2004; 18(3): 293-335
12. National Health Service. Alcohol-use disorders Diagnosis,assessment and management of harmful drinking and alcohol dependence. Available from National Institute for Health and Clinical Excellence, Web site: http://www.nice.org.uk/nicemedia/ live/13337/53194/53194.pdf. Accessed March 19, 2014

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