Alcohol 2011

“The Evil of Drink”

Scottish Specialist Pharmacists in Substance Misuse Group

A little history

Stone Age beer jugs c. 10,000 BC

“Strong drink produces woe, sorrow, contentions, babbling, wounds without cause, redness of eyes”

Proverbs. 23:29-30

“ Shaitan (Satan) wants only to excite enmity and hatred between you with intoxicants…… and turn you away from Allah and prayer. So will you not then abstain?”

Qur’an. 5:90-91

London 1743: ≈ 18 million gallons of gin drunk – population 675,00.

and today: 50.9 million litres of pure alcohol sold in

Scotland in 2009: equivalent to 11.9l per person age >16 (9.6l in England & Wales).

Scots (age >16) on average drink 23 units/week (18 units in England & Wales).

Over a third of both men and women drank more than the recommended daily limit on the heaviest drinking day of previous week

In 2008 more than a third of 15 year olds had drunk alcohol in previous week, with 27% of those drinking more than adult recommended weekly limit.

“Alcohol Statistics Scotland 2011”; ISD Scotland Publications

Cost to society of alcohol misuse

2007

£3,560,000,0003,560,000,000

£1,467m

£727m

£231m

£269m

£866mEconomic/productivitycosts

Healthcare costs

Social care costs

Crime costs

Human costs

“The Societal Cost of Alcohol Misuse in Scotland for 2007”; Scottish Government 2010

What else:

Alcohol misuse – not just about binge drinking or dependence

The “gate-way” drug

Many know that sensible drinking guidelines exist

Less than half understand or recall them

What works: Increasing the price Limiting the supply – density of outlets

hours of sale

Raising the legal drinking age Lowering the drink-driving limit Screening and brief interventions Health Promotion and School based

education Promotion of low or no alcohol drinks

How can pharmacists help?..

Advice on safe drinking practices

Patient screening

Delivery of alcohol brief interventions

Involvement in alcohol detoxes

Dispensing and supervision of relapse prevention medication

One pint of ordinary lager contains about the same amount of alcohol as?

1. One glass of wine2. One double whiskey3. Two cans of cider4. One bottle of alcopop5. One single vodka

Alcohol Quiz:

What are the current daily drinking limits for adults?

1. 2-3 units for women, 3-4 units for men

2. 3-4 units for women, 4-5 units for men

3. 1-2 units for women, 2-3 units for men

4. 4-5 units for women, 5-6 units for men

How long does it take to become alcohol free?

1. Depends on when you finish drinking

2. 1hr per unit 3. 4 hrs per unit4. 30 mins. per unit

A can (440ml) of 4.5% lager is equivalent to?

1. 2 plain digestive biscuits (115 calories)

2. A slice of pepperoni pizza (250 calories)

3. A small Yorkshire pudding (55 calories)

4. 5 Jaffa cakes (221 calories)

Screening and Brief Interventions

Scottish Government funding for Screening and Brief Interventions at GP practices and A & E.

Lack of research evidence means that a role for pharmacy has yet to be specified.

Advice and information, screening and assessment, brief interventions and referral.

Screening and Brief Interventions

Recent pilot study in Grampian - 20 pharmacies

It is possible to screen, give an ABI and refer on in a community pharmacy setting.

Need tailored training which focuses on engaging pharmacy clients for the purpose of screening.

Support is required

Pharmacists’ worries about upsetting patients was largely unfounded

Patients who had received a BI had reduced their weekly drinking by more units than the control group, average FAST score reduced to <3

Fast Alcohol Screening Test

In the past year:

1. How often have you had eight (six) or more drinks on one occasion?

2. How often have you been unable to remember what happened the night before?

3. How often have you failed to do what was expected of you because of drink?

4. Has anyone been concerned about your drinking and suggested you cut down?

Hazardous (risky) drinker: Consistently drinks over recommended

limits, but without alcohol-related problems.

Harmful drinker: Consumes more than the daily and weekly

recommended limit, exhibiting clear evidence of alcohol related problems

Dependant drinker: overpowering desire to drink that is difficult

to control even if aware of harmful consequences. (also shows withdrawal symptoms, tolerance and self neglect.)

A brief intervention is: A time-limited conversation between a

practitioner and patient focused on addressing hazardous and harmful alcohol use.

The aim is to: Motivate hazardous or harmful drinkers to

reflect on their drinking behaviour and reduce their alcohol consumption to lower risk levels.

SIGN 74

2003 but not “out of date”

Includes information about Brief interventions, Detox, and relapse prevention.

Highly recommended - www.sign.ac.uk

NICE GUIDELINES (www.nice.org.uk)

Part 1: Alcohol use disorders in adults and young people: prevention and early identification (June 2010)

Part 2: Alcohol use disorders in adults and young people: clinical management (June 2010)

Part 3: Alcohol use disorders: management of alcohol dependence (Feb 2011)

Alcohol detoxes Aim is to ease the symptoms of

withdrawal, prevent seizures and delirium tremens without over-sedating the patient

Community vs. in-patient

Chlordiazepoxide is the drug of choice (diazepam if patient has history of seizures)

Regime is dependent on the patient and setting i.e. fixed dose or symptom triggered

Detoxification: Fixed chlordiazepoxide regime

10mg 15mg 20mg 30mg

Day 1 10mg qds 15mg qds 20mg qds 30mg qds

Day 2 10mg tds 10mg qds 15mg qds 25mg qds

Day 3 5mg tds 10mg tds 10mg qds 20mg qds

Day 4 5mg bd 5mg tds 10mg tds 15mg qds

Day 5 5mg nocte 5mg bd 5mg tds 10mg qds

Day 6 - 5mg nocte 5mg bd 10mg tds

Day 7 - - 5mg nocte 5mg tds

Vitamin supplementation

Risk of Wernickes-Korsakoffs syndrome due to a lack of thiamine

Pabrinex IV or IM Treatment 2 pairs IV three times daily Prophylaxis 1 pair IM daily

Oral thiamine 100 mg three times daily for everyone at risk

Relapse prevention medication Disulfiram

“alcohol deterrent” due to unpleasant reaction to alcohol

Requires complete abstinence from alcohol therefore not suitable for everyone

Most evidence for it be taken under supervision

Acamprosate Helps to stop the cravings Patients can still drink on this

Naltrexone (unlicensed) Helps to stop the cravings Can not use this if patient is also on methadone

Important drug interactions ALCOHOL + BENZODIAZEPINES

Increased sedation

ALCOHOL + DISULFIRAM Disulfiram-alcohol reaction

Alcohol + metronidazole Disulfiram-like reaction

Alcohol + any sedating drugs (e.g.

antihistamines) Increased sedation

Alcohol + warfarin Affected anticoagulant control

Very important drug interactions!

ALCOHOL + METHADONE

ALCOHOL + HEROIN

ALCOHOL + BENZOS

METHADONE + BENZOS

ALCOHOL + METHADONE + BENZOS

ALCOHOL + HEROIN + BENZOS

Alcohol and drug deaths

+ (+ )

=

Do not give methadone to a patient who appears

intoxicated.

One pint of ordinary lager contains about the same amount of alcohol as? (568ml @ 3.5% = 2 units)

1 glass of wine- 175ml @ 12% 2 units

1 double whiskey – 50ml @ 40% 2 units

2 cans of cider – 880ml @ 5.6% - 8% 5–8 units

1 bottle of alcopop – 275ml @ 5.5% 1.5 units

1 single vodka – 25ml @ 40% 1 unit

What are the current daily drinking limits for adults?

2-3 units daily, and no more than 14 units in a week for women

3-4 units daily and no more than 21 units in a week for men

and at least 2 alcohol-free days a week for both men and women

How long does it take to become alcohol free?

Approximately 1hr per unit

A can (440ml) of 4.5% lager is equivalent to?

5 Jaffa cakes (221 kcal)

2 plain digestive biscuits (115 kcal)

A slice of pepperoni pizza (250 kcal)

A small Yorkshire pudding (55 kcal)