New recommendations for weekly alcohol limits (as of January) are for a 14-unit limit for women and men. This should be spread over at least three days, but not the entire seven (i.e. leave some days free from alcohol).
- Beer or lager has 2 units per pint, but strong beer or lager 3 units per pint.
- Spirits – 1.4 u/drink
- Wine – 1.5u/small glass, 2u/medium glass, 3u/large glass, 10u/750 ml bottle
Discuss in any patients presenting with:
- GI problems
- Abnormal LFTs
- Mental health problems
Screening tests include:
- AUDIT – Alcohol Use Disorders Identification Test
- FAST – Fast Alcohol Screening Test (specificity slightly lower than that of the AUDIT)
- MAST-G – Michigan Alcoholism Screening Test Geriatric version. Useful for older patients.
Management of the heavy drinker
Alcohol abuse can lead to hypertension and AF amongst numerous other things (the grand total of alcohol-related conditions is apparently >60) so the physical assessment of a patient presenting with alcohol abuse should include pulse and BP as well as liver assessment.
Review medications. ADs likely to be ineffective, but the module doesn’t give any specific advice on whether to stop them. Look out for sedating drugs.
Have a brief advice session. Refer to specialist services if that doesn’t help, if the patient is dependent on alcohol, or if there are significant comorbidities such as mental health problems, liver disease, epilepsy, or a history of withdrawal seizures.
Look out for cognitive impairment. Note that to some extent this may recover with abstinence.
Prescribe oral thiamine. The reasons for thiamine deficiency in heavy drinkers are:
- Reduced consumption – poor diet
- Reduced absorption – alcohol blocks absorption
- Reduced storage – liver disease reduces storage capacity.
Urgent detox at home carries risks – refer to specialist services for planned, supervised detox. Risks include delirium tremens and kindling; kindling is a phenomenon whereby repeated withdrawals from alcohol or other sedatives such as benzodiazepines lead to the withdrawal symptoms getting worse each time, and where the cycles of repeated intoxication/acute withdrawal can be associated with profound emotional and behavioural changes such as increased fear, anxiety, and impulsivity. (Interestingly, this process can also occur with regular binge drinkers, so binge drinking can actually be worse than chronic heavy drinking.) Planned withdrawal reduces the risk of kindling by reducing the risk that a withdrawal will fail and hence reducing the number of withdrawals a person is likely to go through.
There is conflicting advice on whether to prescribe Vitamin B compound strong during detoxification. This is partly because they are easier to take than thiamine tablets (which are larger and not very pleasant-tasting) and thus there is a concern that patients may assume they only need to take the Vitamin B compound strong, omit the thiamine, and therefore not get enough thiamine. It may be best only to prescribe them to patients with definite signs/symptoms of alcoholic polyneuropathy; paraesthesia to hands/feet, or proximal muscle weakness.
Typically last between two and 72 hours. The peak of symptoms is around 48 hours (this is when DT symptoms tend to show up) and the peak period for seizures is between 24 and 48 hours.
Symptoms of DT include agitation, disorientation, global confusion, and hallucinations. They can also include physical symptoms – fever, high blood pressure, tachycardia, and hyperhidrosis. DT is a medical emergency, requiring monitoring and benzodiazepine treatment.
Wernicke’s referrs to the encephalopathy, Korsakoff syndrome to the clinical effects. It’s caused by a lack of thiamine and is a medical emergency.
Korsakoff syndrome is an acute onset of severe memory impairment (often associated with the production of fabricated, distorted or misinterpreted memories with no conscious intention of deceiving) without any intellectual dysfunction. It can be associated with ataxia, nystagmus, and paralysis of eye muscles.
(Pulse on-line learning module. Information on drinks content from NHS website.)