Alcohol use – management

Recommendations

DSM-IV Criteria for Alcohol Abuse

• Maladaptive alcohol use leading to significant impairment or distress
• One or more of the following within 12 months:
  • Failure to meet major role obligations
  • Drinking in hazardous situations (e.g., driving)
  • Alcohol-related legal problems
  • Continued use despite interpersonal/social problems
• Does not meet the criteria for alcohol dependence

DSM-IV Criteria for Alcohol Dependence

• Psychobiological syndrome due to neuroadaptive changes in the brain
• Occurs when alcohol intake exceeds 120 g/day (men) or 80 g/day (women)
• Three or more of the following within 12 months:
  • Tolerance (need for increased amounts or diminished effects)
  • Withdrawal symptoms or drinking to avoid withdrawal
  • Drinking more than intended
  • Unsuccessful attempts to reduce consumption
  • Significant time spent obtaining, using, or recovering from alcohol
  • Reduced social, occupational, or recreational activities
  • Continued use despite physical or psychological harm

Drinking Culture in Australia

• Alcohol associated with pleasure, celebration, and life milestones
• In rural areas, linked to values like self-reliance, hardiness, and mateship
• Strong drinking culture in parts of Australian society

Management of Alcohol Use

Screening (From Age 14-15 Onwards, Indefinitely)

• Frequency: Every 3 years or at every visit if high-risk
• Questions: Ask about quantity and frequency of alcohol consumption

Management Using the 5 A’s Approach

• Ask: Inquire about alcohol consumption
• Assess: Evaluate dependence, co-morbidities, and readiness to change
• Advise: Provide brief, personalized, non-judgmental advice to reduce alcohol use
• Assist: Support patients in behavior change, enlist help if needed
• Arrange: Schedule follow-up appointments

Step One – Assessment

Alcohol Use History

• Ask and Quantify:
  • Daily and weekly quantity
  • Duration and timing of use
  • Drinking patterns (regular vs. binge drinking)
  • Time of last and first drink of the day
  • Reasons for alcohol use
• Red Flags for Hazardous or Harmful Drinking
  • Accidents/trauma/falls
  • Psychological/psychiatric issues
  • Family or relationship problems
  • Work/employment issues
  • Involvement in crime
  • Sexual dysfunction
  • Sleep disturbances
  • High-risk groups: Young people, Indigenous Australians
• Previous attempts to abstain or reduce alcohol (reason, outcome, why it failed)
• Withdrawal Symptoms on Cessation
  • Anxiety, tremors, sweating, seizures, delirium, hallucinations
• Medical/Surgical History
  • Gastrointestinal: Fatty liver, alcoholic hepatitis, cirrhosis, peptic ulcers, pancreatitis, carcinoma
  • Neurological: Cognitive impairment, Korsakoff’s syndrome, seizures, Wernicke’s encephalopathy, neuropathy
  • Cardiovascular: Arrhythmias, hypertension, cardiomyopathy
  • Hematologic: Elevated MCV, anemia
  • Psychiatric: Depression, anxiety, insomnia (40% have co-morbid mental disorders)
• Social History
  • Smoking, illicit drug use, living situation, ADLs, employment, relationships
• Family History
  • History of alcohol-related problems in family members

Investigations

• Biological Markers:
  • GGT, AST, ALT, HDL-cholesterol, uric acid, MCV, BAC
  • Elevated GGT in 60-80% of alcohol-dependent individuals
  • MCV elevated in 5-20% of alcohol-dependent individuals

Screening Tools

• CAGE Questionnaire:
  • will still miss 50% of problem drinkers
  • Two “yes” responses indicate that the possibility of alcoholism should be investigated further
  • – do you ever feel the need to Cut down?
  • – do people Annoy you by criticizing your drinking?
  • – do you ever feel Guilty about your drinking?
  • – do you ever feel the need to have an Early morning drink?
• Alcohol Dependence Screen (WHO AUDIT):
  • Identifies hazardous drinking (Score ≥ 7)
  • 10-item tool with sections on alcohol consumption, behavior, dependence, and consequences
  • Sensitivity 90%
• ASSIST Questionnaire:
  • Assesses smoking, alcohol, and drug use
  • Sensitivity 80%, takes 10-20 minutes to complete
• IRIS (Indigenous Risk Impact Screen):
  • For Aboriginal and Torres Strait Islander (ATSI) patients aged 18+

Readiness to Change

• Do you think you have a drinking problem?
• Do you want to change?

Step Two – Management

Management Tailored to:

• Readiness to change
• Degree of alcohol dependence

Stages of Change

• Pre-contemplative: No intention to change
• Contemplative: Ambivalent about changing
• Preparation: Planning for change
• Action: Actively reducing or stopping alcohol use
• Maintenance: Sustaining the change
• Relapse: Returning to risky drinking behavior

Pre-contemplative Stage – Brief Intervention

• Feedback: Personalized advice based on history and risk
• Self-help: Provide information and advice about avoiding dangerous activities (e.g., driving after drinking)

Brief Intervention Strategies to reduce alcohol consumption:

• Identify and avoid high-risk situations
• Enlist support from family and friends
• Start with non-alcoholic beverages
• Switch to drinks with lower alcohol content
• Intersperse alcoholic and non-alcoholic drinks
• Eat before to slow absorption
• Finish a drink completely before refilling glass
• Put glass down between sips
• Engage in activity apart from drinking (e.g. playing pool)
• Avoid rounds
• Practice drink refusal

Contemplative Stage – Motivational Interviewing

• Brief, non-confrontational counselling technique.
• Increases motivation to change by highlighting the discrepancy between goals and current actions.
• Requires an empathic, non-argumentative approach.
• Effective in both risky and dependent drinkers.
• Useful for other lifestyle counselling (e.g., weight loss, exercise, chronic disease management).
• Encourage patient to:
  • weigh up costs and benefits of continued use
  • link psychosocial problems to alcohol misuse
  • look to the future
  • identify strengths and barriers to changing alcohol use
  • Ask patient to rate their motivation and confidence to change

Motivational Interviewing Techniques (OARS)

• Open-ended questions: Encourage detailed responses
• Affirmations: Validate the patient’s efforts
• Reflective Listening: Clarify and reflect back patient’s concerns
• Summarizing: Reinforce key points and understanding

Steps in Motivational Interviewing

Motivational Interviewing (MI) is a patient-centered, guiding method of communication designed to elicit and strengthen motivation for change. Here are the key steps involved in the process:

1. Engage:
   • Build rapport and establish a trusting relationship with the patient.
   • Use open-ended questions, affirmations, reflective listening, and summarizing (OARS).
2. Focus:
   • Narrow the conversation to specific behaviors that need to change.
   • Help the patient identify and clarify their own goals and values.
3. Evoke:
   • Elicit the patient’s own motivations for change by exploring their ambivalence.
   • Use techniques such as:
     • Change Talk: Encourage the patient to talk about their desire, ability, reasons, and need for change.
     • Decisional Balance: Weigh the pros and cons of changing versus not changing.
     • Readiness Ruler: Assess readiness, importance, and confidence regarding change on a scale of 1 to 10.
4. Plan:
   • Develop a plan for change that the patient feels ready to undertake.
   • Collaborate with the patient to set specific, achievable goals.
   • Enhance commitment by helping the patient articulate their plan in their own words.

Core Techniques and Principles:

• Express Empathy: Use reflective listening to show understanding of the patient’s perspective and feelings.
• Develop Discrepancy: Help the patient recognize the gap between their current behavior and their broader goals or values.
• Roll with Resistance: Avoid arguing or confronting. Instead, use reflections and reframing to manage resistance.
• Support Self-Efficacy: Reinforce the patient’s belief in their ability to change by acknowledging past successes and strengths.

Practical Application of OARS:

• Open-ended questions:
  • “What brings you here today?”
  • “Can you tell me more about your drinking habits?”
• Affirmations:
  • “You’ve taken a positive step by coming here today.”
  • “It sounds like you’ve put a lot of thought into this.”
• Reflective Listening:
  • “It sounds like you’re feeling concerned about your health.”
  • “You’re worried that your drinking is affecting your relationships.”
• Summarizing:
  • “Let me see if I understand so far. You’re finding it hard to cut down on drinking because it helps you relax, but you’re also noticing some negative effects on your health and relationships. Is that right?”

Follow-Up:

• Reinforce Changes:
  • Celebrate any positive steps the patient has taken.
  • Continue to support and refine the plan as needed.
• Assess Further Needs:
  • Determine if additional interventions or referrals (e.g., to an AOD counsellor or psychologist) are necessary.

Brief Intervention For Hazardous Alcohol Use

A six-step management plan, which has been employed in a general-practice early intervention program, is as follows:

1. Feedback and Risk Assessment:
   • Provide the patient with the results of your assessment.
   • Explain the specific degree of risk associated with their daily alcohol intake and binge drinking.
   • Emphasize any existing damage to their health.
2. Patient Reaction:
   • Listen carefully to their response.
   • Allow them to vocalize their feelings, even if they respond defensively.
3. Benefits of Reducing Drinking:
   • Outline the benefits, such as saving money, better health, and weight loss.
   • Goal Setting:
     • Collaboratively set feasible goals for alcohol consumption.
     • Aim to reduce intake to below certain ‘safe limits.’
   • For Men: Fewer than 12 standard drinks (SDs) per week.
   • For Women: Fewer than 8 SDs per week. Pregnant women should not drink.
   • For Patients with Illness or Physical Dependence on Alcohol: Long-term abstinence is advisable.
4. Strategies to Maintain Safe Limits:
   • Switch to low-alcohol beer.
   • Explore new interests
     • such as fishing, cinema, social clubs, or sporting activities.
   • Alternate Alcoholic and Non-Alcoholic Drinks:
     • Alternate between alcoholic drinks and water or other non-alcoholic beverages.
   • Set Drink Limits:
     • Decide in advance the maximum number of drinks you will have and stick to it.
   • Drink Slowly:
     • Sip your drinks slowly rather than gulping. Aim to have no more than one standard drink per hour.
   • Avoid Drinking on an Empty Stomach:
     • Eat before or while drinking to slow down the absorption of alcohol.
   • Plan Alcohol-Free Days:
     • Designate certain days of the week as alcohol-free to give your body a break.
   • Measure Your Drinks:
     • Use standard drink measurements to keep track of how much you are actually drinking.
   • Avoid Triggers:
     • Identify situations, places, or people that encourage you to drink excessively and try to avoid them.
     • Be selective about attending parties and avoid high-risk situations.
   • Avoid Peer Pressure:
     • Politely decline offers of drinks and practice saying “no” confidently.
5. Progress Evaluation:
   • Have patients monitor their drinking using a diary.
   • Check for improvements in any abnormal blood test results.
   • Schedule a follow-up appointment and provide appropriate literature, such as Alcohol: Harmful Use of Alcohol.
   • Obtain consent for a telephone follow-up.
6. Follow-Up (Long Consultation 1 Week Later):
   • Review the patient’s drinking diary.
   • Explore any problems they encountered.
   • Summarize their progress, listen, and provide support and encouragement.
   • If the patient misses the appointment, contact them to reschedule.
   • Reinforces changes.

Minimum intervention technique plan (5–10 minutes)

1	Advise reduction to safe levels
2	Outline the benefits
3	Provide a self-help pamphlet
4	Organise a diary or other feedback system
5	Obtain consent for a telephone follow-up
6	Offer additional help (e.g. referral to an alcohol and drug unit or to a support group

Pharmacotherapy

Commence after one week of abstinence

Naltrexone:

• Dose:
  • Starting with 25 mg/day for 1–2 days and
  • then increasing to 50 mg/day is correct.
• Mechanism of Action (MOA): Naltrexone is an opioid receptor antagonist that reduces cravings by blocking the effects of endogenous opioids, thus reducing the pleasurable effects associated with alcohol consumption.
• Effectiveness: Research indicates it can reduce the number of drinking days and the amount consumed in 40–60% of patients, which aligns with what you’ve stated.
• Contraindications (C/I):
  • Naltrexone is contraindicated in patients on opioid analgesia, as it would precipitate withdrawal, and in patients with liver failure or acute hepatitis.
• Side Effects (SE):
• The most common side effects are
  • gastrointestinal (GI) symptoms like nausea
  • fatigue
  • headache
  • anxiety
  • sleep disturbances
• Liver function tests (LFTs) should be checked before initiating therapy, especially given the risk of hepatotoxicity.

Acamprosate:

• Mechanism of Action (MOA): Acamprosate’s mechanism is not entirely clear, but it is believed to act on glutamatergic pathways, helping to stabilize neurotransmission after cessation of alcohol use, reducing cravings and withdrawal-related anxiety.
• Dose: (333 mg tablet) The dosing based on weight is correct:
  • For patients >60 kg: 2 tablets 3 times per day = 1998 mg/day divided into three doses.
  • For patients <60 kg: 2 tablets in the morning, 1 tablet at midday and 1 tablet at night = 1352 mg/day divided into 4 doses.
  • The idea of splitting doses or starting with a lower dose to aid compliance is reasonable.
• Indications: It is recommended for patients who have achieved abstinence and wish to maintain it, which is correct.
• Side Effects (SE):
  • diarrhea
  • insomnia
  • anxiety
  • Itching, skin rash
  • Changes in sex drive.
• Contraindications (C/I): Acamprosate is contraindicated in renal impairment, particularly with creatinine clearance <30 mL/min. Regular renal function monitoring is recommended.

Disulfiram:

• Mechanism of Action (MOA): Disulfiram inhibits the enzyme acetaldehyde dehydrogenase, leading to an accumulation of acetaldehyde when alcohol is consumed.
• This causes unpleasant reactions (flushing, sweating, nausea, etc.) that are meant to deter drinking.
• Dose:
  • 200mg per day
  • Initiate
    • > 7 days after alcohol withdrawal
    • > 48 hrs after last drink
  • The reaction occurs when alcohol is consumed, which serves as a strong deterrent for many patients.
• Side Effects (SE):
  • flushing
  • sweating
  • palpitations
• Contraindications (C/I):
  • severe hypertension
  • diabetes mellitus (DM)
  • heart disease
  • peripheral neuropathy
  • epilepsy
  • renal impairment
  • liver impairment.
• Note on Use: Disulfiram is not considered a first-line treatment anymore due to issues with compliance and potential toxicity. Patients need to be highly motivated and understand the risks of consuming alcohol while on this drug.
• cost: $80-90/month

2^nd line agents to consider

• Selective Serotonin Reuptake Inhibitors (SSRI)
  • Consider especially if comorbid depression
  • Prozac often used, but other SSRIs effective
• Topiramate (Topamax)
  • Decreases Alcohol use severity and heavy, binge drinking
  • Improves abstinence, well being, quality of life in Alcoholics
  • Requires dose titration
• Other medications that may be effective
  • Gabapentin (Neurontin) or Pregabalin (Lyrica)
    • Risk of misuse, especially with Opioids

Medium term – Management

Nutrition

• management should focus on correcting any vitamin deficiencies and ensuring that patients consume a high energy,
• high protein diet of 1.0–1.5 g of protein per kg of lean body weight, either by adjusting the content and frequency of meals and/or by the addition of high energy supplements.
• A snack before bed helps prevent the breakdown of muscle stores overnight.
• Patients who continue to drink should also receive thiamine supplementation to prevent Wernicke-Korsakoff syndrome. 
• once ascites has developed, patients need to avoid salt, including foods with a high salt content
• and its addition to meals.

Prescribing issues

• people with cirrhosis are sensitive to sedatives and anticoagulants are contraindicated in those with decompensation.
• For the unrecognised cirrhotic, surgery and its postoperative course is dangerous. many other medications can be hepatotoxic.
• it is important to educate the patient to check with their doctor before starting any new medications.

Immunisations

• immunocompromised and hyposplenic patients have an increased risk of severe sepsis, and in these groups vaccination should be considered against:
  • pneumococcal
  • meningococcal
  • influenza
  • hepatitis A and B 

Long term – Rehabilitation following withdrawal is needed to:

• Maintain motivation for abstinence; 
• Adjust to new life (e.g. new coping mechanisms, working through losses); 
• Prevent relapse

Setting Realistic Goals:

• Encourage individuals to set specific, measurable, achievable, relevant, and time-bound (SMART) goals related to their alcohol consumption. 
• helps individuals take ownership of their behavior and work towards positive change
  • reducing the number of drinking days per week
  • limiting the number of drinks per occasion.

Gradual Reduction vs Abstinence:

• Gradual reduction can be more effective than recommending abstinence for some patients
• Abstinence is recommended for those with severe alcohol-related organ damage

Behavioral Strategies:

• Cognitive Behavioural Therapy (CBT):
  • Evidence-based for relapse prevention
  • Helps patients learn to manage triggers, cravings, and drink refusal skills
  • Cognitive impairment in patients may limit learning
• Help individuals identify triggers or situations that lead to excessive drinking and develop alternative coping strategies.
  • avoid or cope with high-risk situations
  • finding healthy activities to replace drinking
  • learning effective stress management techniques.
  • avoid or cope with high-risk situations

Social Support:

• Encourage individuals to seek support from family, friends, or support groups. 
• Being surrounded by individuals who support their goal of reducing alcohol use can make a significant difference in their success.

Education and Awareness:

• provide information about the risks and negative consequences of excessive alcohol consumption. 
• This can help individuals understand the impact of their drinking on their health, relationships, and overall well-being.

Stress Management Techniques:

• Teach individuals relaxation techniques such as deep breathing, meditation, or exercise. 
• These strategies can help manage stress, which is often a trigger for increased alcohol consumption.

Management of Cognitive Impairment:

• Mild/moderate impairment can improve with abstinence, nutrition, and social engagement
• Severe impairment (e.g., dementia) may require mental capacity assessment and potential guardianship or institutionalization

Referral to Treatment:

• 12-step AA program
  • Strong evidence for supporting abstinence (systematic review by Kelly et al.)
  • Practitioners can encourage patients to attend AA meetings
  • Self-report of attendance and clinical markers can help monitor engagement
• psychotherapy (supportive or CBT) – GP
• D&A service
• Residential rehabilitation programs
• Treatment of psychiatric and physical co-morbidity

Management of Alcohol-related Complications:

• Cirrhosis and complications (e.g., varices, coagulopathy)
• Hypertension
• Peptic ulcer disease
• Malnutrition and malabsorption
• Thiamine deficiency: Supplementation to prevent peripheral neuropathy and Wernicke encephalopathy
• Neuropsychiatric disorders (e.g., acquired brain injury, alcohol-induced mood disorder)