Alcohol 2015

O God, that men should put an enemy in their mouths to steal away their brains!

that we should, with joy, pleasance, revel, and applause, transform ourselves

into beasts! ~William Shakespeare, Othello

• Drink the first. Sip the second slowly. Skip the third.

• One martini is all right. Two are too many, and three are not enough. ~James Thurber

• ‘Every government that has ever touched alcohol has burnt its fingers in its lurid flames’. - David Lloyd George

Health Effects

• 2.5 million deaths globally• 60 bad things for your health!• 3rd most dangerous thing in the world• x3 more important than DM worldwide

• Seditious, disingenuous, mendacious, duplicitous, fallacious, illusory, beguiling

Maliciously Protean – and not very medical!

In the UK• £3b in UK• 3,000 alcohol related admissions a day• Children and young people in the UK

– 4,000 admitted with alcohol poisoning last year– more likely than those in almost any other European country to have

been drunk by the age of 13 – to have drunk at least once in the last month – have the most positive expectations of drink.”

• Something more here about harms• And alcohol metabolism• And changing effect on liver and brain

Bhala N et al. BMJ 2013;346:bmj.f807

Deaths caused by liver disease in under 65s.

And why is it that in England....

Real numbers...

• 16,087 people in the UK died from liver disease in 2008 (64,000 from IHD)

• Liver disease is the fifth ‘big killer’ in England & Wales, after heart, cancer, stroke and respiratory disease

• Twice as many people now die from liver disease as in 1991

• Liver disease kills more people than diabetes and road deaths combined.

Risk of all cause mortality

(relative to non-drinkers) by level

of alcohol consumption in

women and men.

Ian R White et al. BMJ 2002;325:191

©2002 by British Medical Journal Publishing Group

UK Total Alcohol Consumption, litres per head, 1980 – 2013 

= 9.4l/over 17 year old in 20131 unit = 10ml or 8g alcohol

UK Total Alcohol Consumption, litres per head, 1980 – 2013 

= 9.4l/over 17 year old in 20133 units/day/person over 17

Estimated per capita consumption 1800-1935- gallons/person (wine and spirit x10)

1/3 of all adults still drink over recommended

limits

Guardian Feb 2015

Alcohol and injury• At 30mg/100ml – impairment in

– Cognitive function– Motor coordination– Sensory perception– Alcohol limit in this country 80mg% Scotland/France 50mg%

• It persists beyond alcohol– Study of pilots in a simulator

• At 0% - 10% could not perform the tests!• At 100% - 89% could not• 14 hours later (alcohol gone) – 68% could not

• ½ • violent crime (1.2m) ⅓ all domestic violence (360,000)

Alcohol Industry

• Bonuses for exceeding volume targets• Competitions to sell most number of shots• Pressure to increase singles to doubles

– Up selling witnessed in 18% of surveyed “drunks”• Lobbying to frustrate minimal pricing

• Alcohol consumption with longer hours• “Pre-loading” a big issue

Alcohol, society and politics

• 19% of prison population have a “problem”– Less support than illicit drugs

• Minimum alcohol policy– 45p/unit would see 28,900 less crimes

• Mixed affects– Cardiff more licencing capacity than any other city– Worth £413/year, employing 11,000– And the study for the rise in alcohol-related crime

Alcohol, society and politics

• In Canada, a 10% rise in the cost of reduced alcohol related deaths by 32%

• An analysis of 6 weeks of soap operas showed 162 incidences of heavy drinking, and the harmful consequences were “rarely shown”

• Minimum pricing policy Chief Medical Officer has advocated a minimum cost of 45p per unit– Watered down to

• Clear labelling of units• And a “pledge” to take 2% of alcohol out of circulation

by now (Policy Paper 2010-2015:”Harmful drinking”)

Alcohol, society and politics

• Historically, Tory support for market freedom and connections with the brewing trade have clashed with moral conservatism and the desire to be tough on social disorder; Labour's traditional instinct for business regulation risks looking like an attack on popular cultural activities when it adds to the cost of a pint. While Nick Clegg faces electoral meltdown over tuition fees in 2015, William Gladstone blamed the Liberal Electoral defeat in 1874 on the party's links with the temperance movement and its calls for greater alcohol control, famously complaining that 'we have been borne down in a torrent of gin and beer‘

• It is an offence to sell alcohol to someone who is drunk, or to obtain alcohol for someone who is drunk – very few prosecutions

Harmful6% Men2% Women

Hazardous33% of men16% of Women

DependenceMen 9% Women 4%

Alcohol problem Prevalence UK 2009 (Nat Inf. Centre, NHS – still most up to date statistics for UK)

http://www.hscic.gov.uk/catalogue/PUB10932/alc-eng-2013-tab.xlsx

Alcohol Consumption in the UK

1997 1998 2000 2002 2004 2006 200702468

101214161820

Average Weekly Alcohol Consumption

MalesFemales

Uni

ts o

f Alc

ohol

2009: 39% of men and 31% women had exceeded the recommended safe limit of alcohol drinking.

• Alcohol is 10% of the UK burden of disease and death, making alcohol one of the three biggest lifestyle risk factors for disease and death in the UK, after smoking and obesity

• In 2012 there were 8,367 alcohol-related deaths in the UK, a 19% increase compared to 2001

• The alcohol-related mortality rate of men in the most disadvantaged socio-economic class is 3.5 times higher than for men in the least disadvantaged class, while for women the figure is 5.7 times higher

• In England and Wales, 63% of all alcohol-related deaths in 2012 were caused by alcoholic liver disease

Impact of Alcohol in the UK

1) Cost to NHS- £3.0billion in direct NHS costs (3.2% of total NHS expenditure)- At peak times 70% of A+E admissions

2) Increased Mortality31,000 deaths per year

3) Increased Morbidity– Causally related to at least 60 medical conditions– Intentional and unintentional injuries– UK much worse than the rest of the European Union

• Deaths from liver disease have reached record levels, rising by 20% in a decade

• Liver disease is the only major cause of mortality and morbidity which is on the increase in England whilst decreasing in other European Countries

• Only 6.4% of dependent drinkers access treatment in the UK• Where reported, 40% of clients starting treatment were self-

referrals and 18% were referrals from general practitioners (GPs). Onward referrals from other substance misuse services accounted for 8%

• For every £1 invested in specialist alcohol treatment, £5 is saved on health, welfare and crime costs

• Alcohol is a causal factor in more than 60 medical conditions,

including: mouth, throat, stomach, liver and breast cancers; high blood pressure, cirrhosis of the liver; and depression

Consequences of Excessive Drinking• SOCIAL

– Marriage breakdown– Absence from work– Loss of work– Social Isolation– Poverty– Loss of shelter/home

Consequences of Excessive Drinking

• MENTAL HEALTH– Anxiety– Blackouts– Memory lapses– Depression +/- suicidal ideas– Dementia– Korsakoff’s +/- Wernicke’s Encephalopathy

Consequences of Excessive Drinking

• PHYSICALHypertension

Myopathy

Cirrhosis

Cancers – many!

Pancreatitis

Gastritis

DM

Neuropathy

Cardiomyopathy

Sexual Dysfunction

Harmful and Dependent Drinkers• Disease or habit ?

– Loss of Insight?– Loss of harm avoidance mechanism– Deceit/ concealment/ lies

• A family disease in terms of genetics– Addictive personality is a myth– BUT ? 50% of causation is genetically determined ?– the children of people who are dependent on alcohol are 3–5 times more likely to

develop the disorder than the rest of the population – Epigenetic mechanisms, which control the activity of genes by switching them on and

off, are also being seen as increasingly important in addictions– early life trauma to genes that code for metabolic enzymes, have a role in how the

genetics of addiction unfold. – Childhood trauma. Severe stress in early life is known to dramatically increase the risk

of addiction, and the risk increases with greater trauma exposure– (Nature 522: June 2015)

Harmful and Dependent Drinkers• A family disease, not just the individual. (Safety/

relationships)• Amenable to behavioural mechanisms

– avoid protection, policing, punishing, picking a fight– Al-Anon– Al-Ateen Victim

Perpetrate

Conflict

Rescue

Harmful and Dependent Drinkers

Hazardous drinking & Harmful use

Hazardous: a pattern of alcohol consumption that increases the risk of harmful consequences for the user or others. Hazardous drinking patterns are of public health significance despite the absence of any current disorder in the individual user.

Harmful: refers to alcohol consumption that results in consequences to physical and mental health. Some would also consider social consequences among the harms caused by alcohol.

AUDIT – C

QuestionsScoring system

Your score0 1 2 3 4

How often do you have a drink containing alcohol?

Never Monthlyor less

2 - 4 times per

month

2 - 3 times per

week

4+ times per

weekHow many units of alcohol do you drink on a typical day when you are drinking?

1 -2 3 - 4 5 - 6 7 - 9 10+

How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?

Never Less than monthly Monthly Weekly

Daily or almost daily

Scoring:A total of 5+ indicates increasing or higher risk drinking.An overall total score of 5 or above is AUDIT-C positive.

Rest of Audit Questions

Alcohol dependence

A cluster of behavioural, cognitive, and physiological phenomena that may develop after repeated alcohol use.

• a strong desire to consume alcohol • impaired control over its use, • persistent drinking despite harmful consequences, • a higher priority given to drinking than to other activities

and obligations, • increased alcohol tolerance, • physical withdrawal reaction when discontinued.

Alcohol dependence

• SADQ – useful to estimate levels of dependence:– > / = 31: severe alcohol dependence

• In-patient/ residential setting– 16-30 : moderate dependence

• May manage in community– < 16 : mild physical dependency.

• Usually no detox. Needed

Route to addiction• Attachment disorder • Genetics• Dissatisfaction with self (fear/shyness/self hatred/insecurity/self-contempt/

isolation/ loneliness/ill-equipped/boredom/failure/low self-esteem)

• Conforming• Effect----------------------------------------------------------------------------• Law of diminishing returns• Secrecy/ deception/Denial/ shame/ ‘loss of self’/ ruthless

selfishness/ grandiosity/ emotional immaturity• Becoming 2 people – ‘the switch’

• Restricted emotional growth/ lack of volition• ‘Becoming another person’ limits blame

• Counselling and Psychotherapy research 2013, Vol 13, No 3, 201-209

Group Work

Thinking of the GIT

• Gastritis, Mallory Weiss, reflux, vomiting• Pancreatitis• GI cancers from mouth to rectum• Cirrhosis (remember NASH increases your chances)• Hypertensive gastropathy• Portal hypertension• Liver failureContinued alcohol consumption increases the rate of

progression of cirrhosis from any cause.

Cirrhosis• Cirrhosis is often asymptomatic until there are obvious complications

of liver disease. • Up to 40% of people with cirrhosis may be asymptomatic.• Blood testing for other reasons may reveal abnormal liver function and

prompt further investigation which shows cirrhosis.• Cirrhosis may present with vague symptoms such as fatigue, malaise,

anorexia, nausea and weight loss. • In advanced, decompensated liver disease, presentation may include:• Oedema.• Ascites.• Easy bruising.• Poor concentration and memory.• Bleeding oesophageal varices.• Spontaneous bacterial peritonitis.

Cirrhosis• The progression to cirrhosis variable: weeks or many years.• Around 80-90% of the liver parenchyma needs to be destroyed before

there are clinical signs of liver failure.• The fibrosis distortion of the hepatic vasculature intrahepatic

resistance portal hypertension. • Portal hypertension

– Oesophageal/ gastric/splenic varices (haemorrhoids, Caput Medusae)– Ascites– splenomegally– hypoperfusion of the kidneys, – water and salt retention– increased cardiac output.

• Damage to hepatocytes – impaired liver function and synthesis of important substances such as clotting

factors and albumen– less able to detoxify other substances

Cirrhosis is a chronic diseaseInitial and at least 6 monthly monitoring• LFTs: AST, ALT, AlkP, GGT); AST ↑ >ALT ,GGT (active alcoholics), Albumin ↓ advanced• FBC: occult bleeding; hypersplenism : thrombocytopenia; macrocytosis.• Renal function tests and electrolytes: hyponatraemia ( inapp ADH) reduced eGFR may

represent hepatorenal syndrome.• Red cell folate: diet inadequate • Coagulation screen: abnormal in advanced cirrhosis• Hba1c, Chol/ HDL/ triglycerides ,uric acid• Ferritin: low = diet or blood loss; ferritin: haemochromatosis, acute phase?.• AFP (hepatocellular Ca) – low sens and spec – USS better• USS – depending on results – detect complications of cirrhosis, or hepatocellular

carcinoma (8% 5 year risk)One off/ other tests• Hep B / C infection.• Autoantibody screen: AMA (PBC) ASmMA (CAH)• Alpha-1-antitrypsin • Ceruloplasmin and urinary copper• Serum iron/ TIBC/ Transferrin HFE (haemochromatosis C282Y) if ferritin raised• BMD

Child-Pugh- Turcotte Scoring

If there is PBC or Sclerosing Cholangitis then Bilirubin is classified as :<68=1; 68-170=2; >170=3.

Thinking of the CVS• Possible beneficial effect of 1-2 units regularly – probable up to

32% RRR, BUT this disappears with heavier use of over 3 units at a time:

• General increase in all adverse markers for advancing atherosclerosis

• AF• Alcoholic Cardiomyopathy (5-15 yrs) (reduction in myocytes, LV

dilatation, LV mass increase, reduced contractility)• Cirrhotic cardiomyopathy: Hypertrophy and blunted stress

response• Increased stroke risk – esp mid-life (50’ s and 60’s) – shortens time

to CVA by 5 years ( BP, bleeding, AF)

Thinking Neuro/ M-skeletal

Neuro• Intoxication with loss of consciousness• Withdrawal• Seizures• Subdural haemorrhage• Peripheral neuropathy, • Wernicke-Korsakoff syndrome• Cerebellar degeneration.• Dementia/ memory loss/ reduction in IQ• Optic atrophy

M/SK• Myopathy – proximal, painful worse at end of day• Weakness and cramps• Loss of muscle mass

Help...• The A – Team (?)• CRI http://www.cri.org.uk/content/reach-out-recovery-birmingham/

• In-patient detox – City hospital toxicology• AA 12-steps/ traditions www.alcoholics-anonymous.org.uk

• Al-anon based on 12 steps www.al-anonuk.org.uk

• Alateen www.al-anon.alateen.org/for-alateen

• Addaction www.addaction.org.uk

• Woodbourne Priory www.priorygroup.com/addictions/drug-rehab• Betel www.betel.org.uk• Support4doctors http://sick-doctors-trust.co.uk/

Help

“What we learn to do we learn by doing”

Aristotle

Help• How do we help?• Unconditional positive regard, facts, support, see when sober(make it possible),

engage, be positive, give hope, be supportive (motivational interviewing – ‘catch them saying something positive and go with that’)

• Referral with any complications – eg variceal surveillance/ failure• Prescribe :

– Nutrition – high protein and calories overall– Exercise – Thiamine; Vitamin B Co; Vitamin D?– Detox. Regime (?) Chloriazepoxide– Colestyramine or ?rifampicin– Beta blockade (carvediolol / propranolol) in portal hypertension– Laxatives– Antibiotic prophylaxis (co-amoxiclav) with GI bleeds; PPI etc– Acamprosate (GABA) (666mg tds 6-12/12)/ Naltrexone / Nalmefene (OPOID)– ?? Anti-fibrotics/ transplantation..– Vaccination : Flu/ Pneumonia/ Hep A/ ?risk Hep B

Route to recovery• Therapeutic relationship• Cessation – irrefutable causal link to situation• External agency – not usually first = gradual

– Allow valuing, optimising +ve’s, consequences of alcohol, matter of fact dailogue (truth), letting go

• Combine psychosocial interventions with pharmacotherapy : demonstrated improved outcomes for those with alcohol dependence

• Supportive belonging (unconditional positive regard/ rapport/ hope/ reduced worry)

• Understanding recovery:– Being sober/clean – rediscovery of self– Maintaining – contentedness with self/ reality/ mastery over own intra/inter-

personal relations– Recovery – support/ routines of self care/ widening of repertoire of

interests/ dealing with wounds- own and others– Counselling and Psychotherapy research 2013, Vol 13, No 3, 201-209