Alcohol has been around for a long time and in all civilisations – the discovery of late stone age beer jugs established the fact that humans had purposely fermented beverages at least as early as 10,000 BC and some historians have suggested that beer may have preceded bread as a staple part of the human diet. Fast forward a few thousand years and the great religious texts carry many warnings about the “evil of drink” and the problems caused by intoxication, not only to individuals, but also society at large. There are more references to alcohol in the Bible than lying, adultery, swearing, stealing, Sabbath breaking, cheating, or blasphemy. The verse quoted here shows that it was most definitely taken in sufficient quantities to become drunk with much the same consequences as now. The Qur’an also has a number of references advising followers to avoid alcohol.
In Britain during the 18 th Century Gin posed a particular problem. Originally taken for “medicinal purposes” gin had become a public health hazard. It was said to be the opium of the people – it might lead them to debtors prison or the gallows, drive them to madness, suicide and death, but it kept them warm in winter and masked the hunger pangs of the poorest. The government was forced to take action passing the Gin act which raised the duty on drink and forbade distillers, grocers, chandlers, jails and workhouses from selling gin. In other words they reduced consumption by increasing the price and restricting the supply.
And today: Combining the price of all types of alcohol in off-licences and licensed premises, alcohol was 66% more affordable in 2009 than in 1987. Off trade alcohol in particular has become much more affordable than on trade alcohol since 1987. Beer is 155% more affordable and wines and spirits 126% more affordable in 2009 than they were in 1987. As one might expect whilst the statistics show that the mean number of units drunk per person per week in Scotland is 23 units, the patterns of alcohol consumption vary with age: the 45 to 54 year olds spread out their drinking through the week, drinking less on more days while younger people drink on fewer days, but drink at high levels on these days. Alcohol is considered by many experts to be the “gateway drug” rather than other substances such as cannabis or legal highs and also confers other risks to teenagers - 1 in 6 15 year olds who drunk alcohol reported trying drugs and 1 in 7 reported having unprotected sex as a consequence of alcohol consumption.
So what about the costs of those statistics The annual cost of alcohol misuse has been estimated at around 3 and a half billion pounds; that’s around £700 per year for every adult living in Scotland. £866 million in absenteeism, reduced productivity, unemployment, and premature alcohol related death in the working population £269 million to the NHS which includes the cost of psychiatric and non-psychiatric hospital stays, A&E attendances, GP and practice nurse consultations Outpatient attendances and hospital day cases, ambulance journeys and NHS alcohol services £231m to the social care costs for services supporting individuals, families and children such as care homes, the children’s hearing system and Criminal justice social work £727m for the cost of alcohol related crime – 77% of all young offenders said they were drunk at the time of their offence And £1.467 billion as the cost to society of premature mortality, such as the value of lost activity prior to retirement by non-participants in the workforce and other less tangible social costs associated with life years lost.
Ninety-seven per cent of respondents to the Scottish Crime and Justice Survey 2009/10 considered alcohol abuse in Scotland to be a problem, with almost three quarters (74%) perceiving it as a big problem. Excessive consumption is not limited to particular sections of society but is common across different age groups and socio-economic groups. Men and women who enjoy higher household incomes are significantly more likely to drink on a daily basis, while men living in the most deprived communities are more likely to drink heavily on individual occasions. More encouragingly – I think. When surveyed 95% had heard of measuring alcohol in units but knowledge of the recommended daily limit was around 35 to 40%
Because this is an international problem the world health organisation has conducted large amounts of research and produce reports on a pretty regular basis. They have looked across the world, in different countries and cultures and observed what works well and what works less well when it comes to trying to reduce the amount of alcohol a population drink. There has been much controversy and many newspaper column inches devoted to the first two on this list. The fact is that increasing the price and limiting the supply (by restricting licenses and outlets) works but substantial and radical action in these areas has little merit in political terms and is deemed to have an impact both on people who do drink sensibly and the employers and employees in the drinks and entertainment industries. The 5 th and 6 th action is where pharmacy may have a role
With respect to health promotion – know you’re units and guidelines. Be prepared to give information, in a non-judgmental way, about the safe limits for drinking and strategies for reducing the amount drunk such alternating alcoholic drinks with non-alcoholic drinks or switching to a lower alcohol alternative. Think about targeting specific groups of patients – repeated requests for indigestion remedies for example or young girls wanting emergency hormonal contraception. Be able to answer questions from concerned parents or family members and know which services are available locally for referral. Get involved with national and local events such as Alcohol Awareness Initiatives
Here are selection of materials that are available if you would like to hold an event in your pharmacy. The photos are of a community pharmacy window display and an event were a community pharmacy hosted a counsellor from a local alcohol service.
How well do you know your units? The next four slides are to test your knowledge – the answers are at the end of this session.
Screening and Alcohol Brief interventions have been shown to be effective in reducing a persons alcohol consumption. There have been a lot of pilot projects showing that screening, brief interventions and referral to alcohol services are possible in a community pharmacy setting and pharmacy research, that will hopefully provide evidence of the benefits, is ongoing.
Chief Scientist Office funded a pilot study to inform the development and conduct of a large-scale RCT rather than assess the effectiveness of screening and ABI in a community pharmacy setting. It examined the provision of an ABI in community pharmacies in terms of practical consideration - recruitment of pharmacists and clients, uptake, potential effectiveness and acceptability to pharmacists and clients. The pilot involved 20 pharmacies – all did the screening but only the 10 pharmacies in the active group gave a “brief intervention” – the 10 in the control group gave out a leaflet with general healthy living advice. This pilot study – that can not be analysed statistically because they were not dealing with large enough numbers) found: It is possible to screen and give brief interventions in a pharmacy setting (previously it had only been recognised as successful in a General Practice setting and in A & E That the training given to pharmacists and pharmacy staff has to be specifically tailored for that setting – and this study has indicated what works and what doesn’t Like all the other programmes going on in pharmacy – it works much better if there is dedicated support – in this case the research team needed to provide that support rather than just wait for the results to roll in. · Pharmacists’ worries about upsetting patients by enquiring about their drinking habits was not borne out by experience or from the responses of the (small) patient study group. · Those patients who had received a brief intervention and responded to the follow-up questionnaires had reduced their self-reported weekly drinking by more units than the control group, with the average FAST screening score reduced to <3. ·
What is screening – well there are a number of different ones but this one – the FAST test is quick and relatively simple. The answers to these four questions and a scoring system will indicate what type of drinker the patient is. The minimum score is 0 and the maximum 16. A score of 3 or more indicates a hazardous drinking pattern. There is more information in SIGN Guideline 74 on screening tests.
The classification for types of drinking patterns are hazardous, harmful and dependent. A hazardous drinking pattern puts the user at increased risk of harmful consequences in the short and longer term. Harmful drinker. As for hazardous drinker but with clear evidence of alcohol related problems that do not necessarily result in the patient seeking treatment. Bothe hazardous and harmful drinkers may respond to a brief intervention. A dependant drinker cannot go without alcohol for any substantial length of time and is unlikely to be able to respond to a brief intervention
Having identified the type of drinker a brief intervention may be given. In community pharmacy we could run a campaign screening anyone who consented – or we could target specific patients such as those requesting hangover treatment, indigestion remedies, sleeping aids, emergency hormonal contraception or complaining of a mildly depressed mood. It is not as easy as smoking cessation – peoples attitudes are different and we are not saying all drinking is bad for you. On the plus side is the experience that shows people are not as reluctant to talk about the issues as you might expect – be confident and think how you might give information in a matter-of-fact, non judgemental way. Not “ your drinking is putting your health at risk” but “evidence shows that drinking more than the recommended amount on a regular basis increases the risk to your health”. Suggestions can be made of ways of reducing a persons drinking - if someone drinks 2 or 3 large glasses of wine a change to three drinks of a (single measure) spirit with a mixer gives you a reduction from a possible 9 units to 3. Changing to a lower strength beer can also decrease alcohol intake by as much as a half.
What guidelines are there to help us? Sign Guideline 74 may have been published in 2003 but a more recent assessment concluded that it is still relevant and should be used to inform services. It has much useful information in it and is recommended additional reading to this module.
Although NICE informs English and Welsh organisations this set of three recently published guidelines have much to recommend them. Part 1 – NICE public health guidance 24 is a public health document looking at how to reduce the exposure to alcohol and is for the government, industry and commerce and the NHS service planners, not so much those delivering services on the ground. Part 2 - NICE clinical guideline 100 covers the physical complications of alcohol misuse and the management of acute withdrawals including Delirium Tremens, Wernicke’s encephalopathy and alcohol-related liver damage and is probably most applicable to hospital pharmacists Part 3 – NICE Clinical guideline 115 looks at identification, prevention and management of alcohol dependence, the use of relapse prevention medication and management of patients in the community.
Why do alcohol detoxifications? Some drinkers who wish to stop feel unable to do so without some help. What hinders their attempts and their chance of success is the withdrawal symptoms they experience when they stop even for a relatively short time. A small proportion of drinkers may become seriously ill if they stop drinking without medical help - unlike withdrawal from opiates – where the symptoms are unpleasant, but do not carry a risk of seizures or death - the sudden cessation of drinking in a seriously dependant drinker can have serious and on occasion fatal complications. Symptoms of withdrawals include agitation, tremor, anxiety, autonomic over activity and seizures Dependant drinkers could reduce their consumption gradually and stop over a period of time but many will have tried and failed that method and for some there will be an urgent need because of an associated health problem. Patients who are stable, have no complex history i.e. seizures, or co-morbid health issues could be detoxed in the community. GP or community addiction services may prescribe the detox. Patient will be well monitored and doses may be supervised by family/friends, addiction services or community pharmacists. Community detoxes tend to follow a fixed dose regime so that the patient and carer know what dose is to be taken and when. More complex patients would require admission to hospital for an organised detox or some people may present to a general hospital and develop withdrawals. Dependent on the hospital policy patients may be commenced on a symptom triggered regime i.e. dose is dependent on how bad the withdrawals symptoms are using a rating scale such as CIWA-Ar or a fixed dose detox (this might be higher than that used in the community). It is the role of the hospital pharmacist to ensure that detoxes are appropriately prescribed, especially that a the doses of a fixed dose regime are titrated down. Benzodiazepines are currently the best drug group for alcohol dependence detoxification. However benzodiazepines, and especially diazepam are associated with misuse and alcohol related death. Chlordiazepoxide has a more gradual onset of its psychotropic effects, and therefore may be less toxic in overdose. Probably because of the chlordiazepoxide is less often “misused” and has a lower illicit, or “street”, value. Other drugs you would expect the patient to prescribed would be rectal diazepam in the event of the patient experiencing a seizure.
Most withdrawal symptoms occur within the first three days of stopping drinking – traditionally a seven to 10 day programme is offered recognising the acute withdrawal state may be delayed in a small minority of patients. The starting dose is decided by assessing the patients current consumption and the severity of their alcohol dependence. Whilst symptom triggered chlordiazepoxide dosing might be considered as “gold standard” it requires careful and regular monitoring throughout the day. A tapered fixed dose chlordiazepoxide regime as illustrated here is likely to be as effective in primary care with daily monitoring whenever possible.
Wernicke’s encephalopathy is a acute life–threatening neurologic disorder resulting from a lack of thiamine (vitamin B1) which affects the brain and nervous system. The condition may be precipitated by detoxification. Symptoms include: Confusion, ataxia ( a group of neurological disorders that affect balance, coordination, and speech), memory disturbance, hypothermia and hypotension, the eye conditions Opthalmoplegia and nystagmus and lastly coma. It can be fatal and even those who survive have a high risk of developing Korsakoff’s psychosis. Vitamin supplementation is a vital part of treatment for patients with alcohol problems and the importance of replacing thiamine can not be over estimated. In a community setting you would expect patients to be prescribed oral thiamine 100 mg tds. Although some Addiction teams will use parenteral thiamine i.e. Pabrinex, this is uncommon and you would only very rarely be asked to supply it on a prescription. In a hospital setting you would expect patients to be on parenteral thiamine i.e. Pabrinex. This comes in two forms, the choice of which is used depends on the diagnosis. IV if patients have a diagnosis of WE then IM if patients are at risk of WE Then oral thiamine 100 mg three times daily There is a greater risk of anaphylaxis with the IV preparation. You might be familiar with the bright yellow IV bag seen on the wards, the Pabrinex should be diluted in 50-100 ml and infused over 30 mins to minimise the risk. The IM injection is oily and 7mL, therefore quite large so is very sore for patients!
Disulfiram works by irreversibly inhibits aldehyde dehydrogenase (ALDH) leading to acetaldehyde accumulation from incomplete alcohol metabolism after drinking alcohol which cause extremely unpleasant systemic physical reaction. It therefore helps in relapse prevention by detering the patient from taking any alcohol. Symptoms develop within 10 minutes of drinking and severity depends on the amount of alcohol consumed and the individual and include flushing of face and upper body, throbbing headache, palpitations, dyspnoea, tachycardia, nausea and vomiting and arrhythmia, hypotension and collapse. It can be fatal. Disulfiram dose is usually 200 mg daily but it is commonly prescribed 400 mg three times a week. Most evidence for disulfiram comes from trials where administration has been supervised to ensure patients take their tablets during times of ambivalence. If people have support at home a family member can do this, but some patients come to the community pharmacy, especially if they are also on methadone. Acamprosate has been shown to reduce the risk of relapse during the postwithdrawal period. It is a safe drug with few unwanted side effects and is not liable to misuse. It is useful for patients who are concerned that strong cravings will result in relapse. It should be initiated as soon as possible after abstinence has been achieved and be continued (if assessed as effective) for 6 months to a year. Treatment can be continued if there is a temporary relapses but should be stopped if the patient returns to regular or excessive drinking. The dose is dependant on weight. Naltrexone can also be affective at preventing relapse by blocking the effects of alcohol. It may be used by specialists but remains unlicensed for alcohol dependence in the UK. As it also blocks the effects of opiates it is not suitable for patients on methadone. All the evidence suggests that these therapies do not work well on their own but must be accompanied by psychological interventions such as cognitative behavioural therapy or psychosocial support. Alcohol dependent patients should also be encouraged to attend Alcoholics Anonymous.
Here is a reminder of some important alcohol- drug interactions.
Chronic alcohol use may lead to changes in the liver resulting in more rapid metabolism of methadone leading to more rapid withdrawal and requests for increased methadone doses or greater illicit opiate use.
And finally alcohol and heroin or methadone is not a good combination. The drug death statistics show that a substantial proportion of overdose deaths are as a result of taking an opiate with alcohol (often deliberately to sustain a hit) with a handful of benzos thrown in sometimes for good measure
What are the options if a patient comes in for their methadone in an intoxicated state? If there is time the could return later the same day. If not then it is safer to withhold a dose completely. Methadone is long acting and therefore one missed dose unlikely to cause symptoms of withdrawal. It is advisable to contact the prescriber, especially if it becomes a regular issue.
And the answers to those questions
“ The Evil of Drink” <ul><li>Scottish Specialist Pharmacists in Substance Misuse Group </li></ul>
A little history <ul><li>Stone Age beer jugs c. 10,000 BC </li></ul><ul><li>“ Strong drink produces woe, sorrow, contentions, babbling, wounds without cause, redness of eyes” </li></ul><ul><li>Proverbs. 23:29-30 </li></ul><ul><li>“ 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?” </li></ul><ul><li>Qur’an. 5:90-91 </li></ul>
<ul><li>London 1743: ≈ 18 million gallons of gin drunk – population 675,00. </li></ul>
and today: <ul><li>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). </li></ul><ul><li>Scots (age >16) on average drink </li></ul><ul><li>23 units/week (18 units in England & Wales). </li></ul><ul><li>Over a third of both men and women drank more than the recommended daily limit on the heaviest drinking day of previous week </li></ul><ul><li>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. </li></ul><ul><li>“ Alcohol Statistics Scotland 2011”; ISD Scotland Publications </li></ul>
Cost to society of alcohol misuse 2007 £ 3,560,000,000 “ The Societal Cost of Alcohol Misuse in Scotland for 2007”; Scottish Government 2010
What else: <ul><li>Alcohol misuse – not just about binge drinking or dependence </li></ul><ul><li>The “gate-way” drug </li></ul><ul><li>Many know that sensible drinking guidelines exist </li></ul><ul><li>Less than half understand or recall them </li></ul>
What works: <ul><li>Increasing the price </li></ul><ul><li>Limiting the supply – density of outlets hours of sale </li></ul><ul><li>Raising the legal drinking age </li></ul><ul><li>Lowering the drink-driving limit </li></ul><ul><li>Screening and brief interventions </li></ul><ul><li>Health Promotion and School based education </li></ul><ul><li>Promotion of low or no alcohol drinks </li></ul>
How can pharmacists help?.. <ul><li>Advice on safe drinking practices </li></ul><ul><li>Patient screening </li></ul><ul><li>Delivery of alcohol brief interventions </li></ul><ul><li>Involvement in alcohol detoxes </li></ul><ul><li>Dispensing and supervision of relapse prevention medication </li></ul>
One pint of ordinary lager contains about the same amount of alcohol as? <ul><li>One glass of wine </li></ul><ul><li>One double whiskey </li></ul><ul><li>Two cans of cider </li></ul><ul><li>One bottle of alcopop </li></ul><ul><li>One single vodka </li></ul>Alcohol Quiz:
What are the current daily drinking limits for adults? <ul><li>2-3 units for women, 3-4 units for men </li></ul><ul><li>3-4 units for women, 4-5 units for men </li></ul><ul><li>1-2 units for women, 2-3 units for men </li></ul><ul><li>4-5 units for women, 5-6 units for men </li></ul>
How long does it take to become alcohol free? <ul><li>Depends on when you finish drinking </li></ul><ul><li>1hr per unit </li></ul><ul><li>4 hrs per unit </li></ul><ul><li>30 mins. per unit </li></ul>
A can (440ml) of 4.5% lager is equivalent to? <ul><li>2 plain digestive biscuits (115 calories) </li></ul><ul><li>A slice of pepperoni pizza (250 calories) </li></ul><ul><li>A small Yorkshire pudding (55 calories) </li></ul><ul><li>5 Jaffa cakes (221 calories) </li></ul>
Screening and Brief Interventions <ul><li>Scottish Government funding for Screening and Brief Interventions at GP practices and A & E. </li></ul><ul><li>Lack of research evidence means that a role for pharmacy has yet to be specified. </li></ul><ul><li>Advice and information, screening and assessment, brief interventions and referral. </li></ul>
Screening and Brief Interventions <ul><li>Recent pilot study in Grampian - 20 pharmacies </li></ul><ul><li>It is possible to screen, give an ABI and refer on in a community pharmacy setting. </li></ul><ul><li>Need tailored training which focuses on engaging pharmacy clients for the purpose of screening. </li></ul><ul><li>Support is required </li></ul><ul><li>Pharmacists’ worries about upsetting patients was largely unfounded </li></ul><ul><li>Patients who had received a BI had reduced their weekly drinking by more units than the control group, average FAST score reduced to <3 </li></ul>
Fast Alcohol Screening Test In the past year: <ul><li>How often have you had eight (six) or more drinks on one occasion? </li></ul><ul><li>How often have you been unable to remember what happened the night before? </li></ul><ul><li>How often have you failed to do what was expected of you because of drink? </li></ul><ul><li>Has anyone been concerned about your drinking and suggested you cut down? </li></ul>
Hazardous (risky) drinker: <ul><li>Consistently drinks over recommended limits, but without alcohol-related problems. </li></ul><ul><li>Harmful drinker: </li></ul><ul><li>Consumes more than the daily and weekly recommended limit, exhibiting clear evidence of alcohol related problems </li></ul><ul><li>Dependant drinker: </li></ul><ul><li>overpowering desire to drink that is difficult to control even if aware of harmful consequences. (also shows withdrawal symptoms, tolerance and self neglect.) </li></ul>
A brief intervention is: <ul><li>A time-limited conversation between a practitioner and patient focused on addressing hazardous and harmful alcohol use. </li></ul><ul><li>The aim is to: </li></ul><ul><li>Motivate hazardous or harmful drinkers to reflect on their drinking behaviour and reduce their alcohol consumption to lower risk levels . </li></ul>
SIGN 74 <ul><li>2003 but not “out of date” </li></ul><ul><li>Includes information about Brief interventions, Detox, and relapse prevention. </li></ul><ul><li>Highly recommended - www.sign.ac.uk </li></ul>
NICE GUIDELINES (www.nice.org.uk) <ul><li>Part 1: Alcohol use disorders in adults and young people: prevention and early identification (June 2010) </li></ul><ul><li>Part 2: Alcohol use disorders in adults and young people: clinical management (June 2010) </li></ul><ul><li>Part 3: Alcohol use disorders: management of alcohol dependence (Feb 2011) </li></ul>
Alcohol detoxes <ul><li>Aim is to ease the symptoms of withdrawal, prevent seizures and delirium tremens without over-sedating the patient </li></ul><ul><li>Community vs. in-patient </li></ul><ul><li>Chlordiazepoxide is the drug of choice (diazepam if patient has history of seizures) </li></ul><ul><li>Regime is dependent on the patient and setting i.e. fixed dose or symptom triggered </li></ul>
Vitamin supplementation <ul><li>Risk of Wernickes-Korsakoffs syndrome due to a lack of thiamine </li></ul><ul><li>Pabrinex IV or IM </li></ul><ul><ul><li>Treatment 2 pairs IV three times daily </li></ul></ul><ul><ul><li>Prophylaxis 1 pair IM daily </li></ul></ul><ul><li>Oral thiamine 100 mg three times daily for everyone at risk </li></ul>
Relapse prevention medication <ul><li>Disulfiram </li></ul><ul><ul><li>“ alcohol deterrent” due to unpleasant reaction to alcohol </li></ul></ul><ul><ul><li>Requires complete abstinence from alcohol therefore not suitable for everyone </li></ul></ul><ul><ul><li>Most evidence for it be taken under supervision </li></ul></ul><ul><li>Acamprosate </li></ul><ul><ul><li>Helps to stop the cravings </li></ul></ul><ul><ul><li>Patients can still drink on this </li></ul></ul><ul><li>Naltrexone (unlicensed) </li></ul><ul><ul><li>Helps to stop the cravings </li></ul></ul><ul><ul><li>Can not use this if patient is also on methadone </li></ul></ul>
Important drug interactions <ul><li>ALCOHOL + BENZODIAZEPINES </li></ul><ul><ul><li>Increased sedation </li></ul></ul><ul><li>ALCOHOL + DISULFIRAM </li></ul><ul><ul><li>Disulfiram-alcohol reaction </li></ul></ul><ul><li>Alcohol + metronidazole </li></ul><ul><ul><li>Disulfiram-like reaction </li></ul></ul><ul><li>Alcohol + any sedating drugs (e.g. antihistamines) </li></ul><ul><ul><li>Increased sedation </li></ul></ul><ul><li>Alcohol + warfarin </li></ul><ul><ul><li>Affected anticoagulant control </li></ul></ul>
Very important drug interactions! <ul><li>ALCOHOL + METHADONE </li></ul><ul><li>ALCOHOL + HEROIN </li></ul><ul><li>ALCOHOL + BENZOS </li></ul><ul><li>METHADONE + BENZOS </li></ul><ul><li>ALCOHOL + METHADONE + BENZOS </li></ul><ul><li>ALCOHOL + HEROIN + BENZOS </li></ul>
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)