Lecture 43: Alcohol misuse and management

What are the 5 steps for alcohol intervention care strategies?

1. Structured brief advice

2. Extended brief intervention

3. Psychological intervention

4. Refer to specialise alcohol treatment service

5. + prophylactic oral tx if they are malnourished/at risk of malnourishment and/or decompensated liver disease due to drinking

What does structured brief advice include?

• Short conversation giving information about risks of drinking, advise to cut down and help set simple goals

• Used for someone drinking above recommended limits but not dependent

What does extended brief intervention include?

• A longer motivational intervention, maybe multiple sessions, includes exploring pros/cons of drinking, helps set up personalised reduction plan and provides written materials or follow up appointments

• Used for people with more risky drinking/mild dependence

What does psychological intervention include?

• More structures therapy like CBT, motivational enhancement therapy, social behaviour and network therapy

• Delivered over several sessions to help change long term drinking patterns

What does referring to specialise alcohol treatment services include?

• Used when someone has moderate/severe alcohol dependence, failed primary care interventions, significant withdrawal risk and co-existing mental health or medical conditions

• Specialist services can provide detox, community teams, rehabilitation

What does adding use of prophylactic oral treatment involve and why is this used?

• Options: thiamine, acamprosate

• Because alcohol dependence commonly leads to vitamin deficiencies

What does fixed dose regimens involve?

• Involves standard initial dose of chlordiazepoxide/diazepam (determined by level of consumption)

• Followed by dose reduction to 0 over 7-10 days

What do symptom triggered approaches involve?

• Tailors drug regimen according to severity of withdrawal and any complications to a specific patient

• Adequate monitoring facilities should be available

• Patient monitored on regular basis and treatment only continued as long there are withdrawal symptoms

When should hospital admission be offered during alcohol withdrawal?

If the patient is at risk of withdrawal seizures or delirium tremens

Which groups should have a lower threshold for hospital admission?

Frail individuals, those with cognitive impairment, multiple comorbidities, lack of social support, or learning disabilities

What is recommended in secondary care for patients at risk of severe withdrawal symptoms?

Medically-assisted withdrawal programmes

What clinical signs may indicate alcohol-related complications requiring specialist referral?

Raised temperature, pulse, respiratory rate; unintentional weight loss; tender abdomen; diarrhoea/vomiting; jaundice; bleeding; ascites

What should you do if a patient has a high suicide risk?

Refer urgently to mental health services

What medication class is recommended to reduce alcohol withdrawal symptoms and what drug is an unlicensed alternative?

Long-acting benzodiazepines (e.g., chlordiazepoxide or diazepam)

Carbamazepine is an unlicensed alternative

What is Wernicke’s encephalopathy and the key symptoms to look out for?

A serious neurological condition caused by thiamine deficiency, often due to alcohol misuse

Symptoms: confusion, nystagmus, memory issues, hypothermia, hypotension, coma

What is the treatment for Wernicke’s encephalopathy?

Immediate parenteral thiamine (IV Pabrinex), followed by oral thiamine

How do treatment approaches differ between primary and secondary care in the management of alcohol withdrawal?

Primary care manages mild–moderate dependence using:

• Structured brief advice

• Extended brief interventions (up to 5 sessions)

• Psychological therapies (CBT, MET, etc.)

• Prophylactic oral thiamine (± acamprosate)

• Community management for moderate dependence

• Referral to specialist services if severe, high-risk, or complications

Secondary care is used for higher-risk or severe withdrawal, offering:

• Medically-assisted withdrawal programmes

• Admission for risk of seizures or delirium tremens

• Benzodiazepine regimens (fixed-dose or symptom-triggered)

• Management of complications (e.g., hepatic disease, pancreatitis)

• Urgent mental health referral if suicide risk