Alcohol (Part 1)
Epidemiology and Assessment
© 2009 University of Sydney
Learning outcomes
By completing this module, participants will
be able to:
• Describe the epidemiology of alcohol problems in
Australia
• Obtain an alcohol history
• Describe the acute and chronic complications of
alcohol use disorders
• Perform a relevant physical examination
• Describe the role of blood tests in assessing alcohol
use disorders
Case: Mr H.
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60 y.o. man, interviewed via interpreter
Type 2 diabetes, oral hypoglycaemics
Hypertension
Admitted to hospital, drowsy after falling
and banging head
Smells of alcohol
Reports max 4 glasses spirits/day
14cm Hepatomegaly
GGT 1042 U/L
Mr H: input from daughter
• Drinks up to a bottle of whisky per
day
• Wife finding it difficult to cope with
repeated falls and is considering a
nursing home
Mr H: issues
• How common are alcohol use disorders
and their complications?
• How to take a good alcohol history?
– When is a drinker dependent?
• Can we simply assume his liver problem
is related to alcohol?
Epidemiology
Alcohol use in Australia
• Nine out of every ten Australians aged
14 years or older (89.9%) had tried
alcohol at some time in their lives.
• 82.9% had consumed alcohol in the 12
months preceding the 2007 survey
Australian Institute of Health and Welfare, 2008
Alcohol abuse in Australia
• Prevalence of alcohol use disorders = 6%
of Australian population
• Alcohol-related conditions account for
– up to 40% of ED presentations
– up to 30% of hospital admissions
– about 50% of D&A CL activity
NSMHWB, 2007;
Charalambous 2002, Alcohol, 37;
Conigrave et al 1991 Med J Aust, 154;
Pols &Hawks, 1992
Impact of Drugs and Alcohol
on hospitals: 2004/5
Deaths
Hospital bed days
Hospital costs
($M)
Tobacco
14,901
753,618
669.6
Alcohol
1,057
916,934
693.9
Opiates
228
22,463
13.1
Cannabis
1
7,287
3.1
ATS
17
5,288
3.4
Licit,
combined,
unspecified
483
40,811
23.0
Collins & Lapsley 2008, Commonwealth of Australia
Assessment
Alcohol Consumption
• Every patient needs a quantified
drinking history
• Episodic drinking is common
• Make it easy for the patient to admit to
heavy drinking
• e.g. suggest a high level of drinking
What is a standard drink?
NB: home or restaurant poured drinks are variable but are
approximately 2 standard drinks
Drink-less Program, 2005
Non-standard drinks
Drink-less Program, 2005
Non-standard drinks
• Home or restaurant-poured drinks
are often larger
– Home poured wine and spirits are
typically 2-3 standard drinks
– Check rate of purchase of
bottle/flagon
– Assess by packaged units (e.g.
number of bottles of wine or spirit
purchased per week)
Low risk drinking levels
NHMRC Australian guidelines to reduce health
risks from drinking alcohol (2009):
1. For reduced lifetime risk of harm from drinking:
2 standard drinks or less in any 1 day (for healthy men
and women, aged 18 and over)
2. For reduced risk of injury in a drinking occasion:
No more than 4 standard drinks per occasion
3. For people <18 years of age: safest not to drink
Under 15: Especially important not to drink
Between 15-17: Delay drinking initiation for as long as
possible
4. Pregnant (or planning a pregnancy) or Breastfeeding: Not
drinking is safest option
Some definitions
• Hazardous use: drinking patterns that
increase the risk of adverse
consequences for the user or others.
• Harmful use: already experiencing
consequences to physical or mental
health from drinking. Could also
include social consequences.
Babor et al, 2001, WHO
Some definitions
Dependence – ICD10
• Three or more criteria present:
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Compulsion to drink
Loss of control
Tolerance
Salience/neglect of alternative interests or
obligations
– Withdrawal symptoms
– Persistent drinking despite harm
WHO, 2007
Why the definitions are
important
• Dependent drinkers usually need to
stop drinking and may experience a
withdrawal syndrome
• Hazardous or harmful drinkers can
usually cut down
Types of drinkers (adults)
5%
15%
65%
15%
High risk/dependent
At risk
Low risk
Non-drinker
Teesson, 2000 ANZ J Psych, 34 (NSMHWB)
Assessment of drinking
• Alcohol consumption
• Presence of dependence
• Desire to change drinking, past
attempts to cut down or stop
–Experienced withdrawals?
Assessment of drinking
(cont’d)
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Consumption level
Presence of dependence
Desire to change drinking, past attempts
Complications/comorbidity
– Physical and psychiatric problems
• e.g. hep C, obesity
– Other substance use
• Benzodiazepines, opiates
(licit/illicit), cannabis, stimulants
Assessment of drinking
(cont’d)
• Other factors which could make
change difficult:
– Housing
– Employment
– Social/family environment
Risk factors for alcohol
use disorders
• Genetic
– Polygenic
– 4x risk of dependence if dependent father,
even if reared apart
– Males > females
• Environmental/social
– Availability (including cost and ease of
access), occupation, peer/family behaviour
– Psychological trauma (e.g. childhood
abuse), unemployment
• Psychiatric illness
Natural history of
dependence
• Most common in young adult men, aged
18-34 years
• Overall consumption falls with age except
for severely dependent drinkers
• A chronic relapsing condition
• Only 5% return to stable controlled
drinking without treatment
Acute complications
• Account for around 50% of the harm
associated with drinking
• Trauma, physical/sexual assault,
unprotected sex, harm to others,
suicide, drowning, burns,
arrhythmias
Chronic complications
• Can affect every body system
• Seen in more advanced, long
standing drinkers
• Many dependent drinkers have
none
Chronic complications
cont’d
• GI: liver, dyspepsia, diarrhoea, delayed
healing of peptic ulcer, pancreatitis
• Psychiatric: depression, suicide
• Neurological: cognitive impairment,
wernicke/korsakoff’s, neuropathy, stroke
• CVS: hypertension, cardiomyopathy,
arrhythmias
Chronic complications
cont’d
• Nutritional: thiamine, folate, B12, malnutrition
• Musculoskeletal: osteoporosis, myopathy
• Immune: ↓T-cell function
• Respiratory from associated smoking, TB
• Renal: electrolyte disorders
• Endocrine: cortisol, ↓testosterone, type 2
diabetes
• Cancer: aerodigestive, breast, rectum
• Fetal development: fetal alcohol syndrome
Early symptoms and signs
of chronic alcohol problems
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Hypertension
Insomnia
Indigestion/diarrhoea
Anxiety
Depression
Sick days
Alcohol induced liver disease
Overlapping processes:
• Fatty liver
– reversible
• Alcoholic hepatitis
– Severe cases rare
• Cirrhosis
– Largely irreversible
– 15% persons drinking 150g/d for 10+
yrs
Why does alcohol cause
organ damage?
• Multiple factors, varies between organs
• Harmful consequences of metabolism
– Oxidative (acetaldehyde toxicity, oxidant
stress, acidosis)
– Non-oxidative (fatty acid ethyl esters damage
membranes)
• Nutritional impairment
• Endotoxinaemia
– Abnormal gut absorption of bacterial products
Does alcohol really have
health benefits?
Moderate drinking and
coronary heart disease
Lipids
(HDL-C and Triglycerides)
Hemostatic Function (Fibrinogen)
Alcohol
Insulin Sensitivity
Other
Coronary
Heart
Disease
Moderate consumption apparently
reduces total mortality
Mortality by alcohol consumption
Relative risk
1.80
1.40
1.00
0.60
abstain
1-1.9
3-3.9
5-5.9
standard drinks per day
Men
Women
Holman et al, Meta-analysis, 1996, MJA, 164
No reduction of mortality
in young people
15 year mortality in Swedish army
Odds ratio
2.5
2
1.5
1
0.5
0
<15 g/d
15-29 g/d
30+ g/d
m ean daily alcohol at recruitm ent
Andreasson et al, 1991, British Journal of Addiction, 86, 379-382
Health benefits of alcohol
are still uncertain
• Restricted demographic:
– Overall, most harms and fewest benefits
occur in young people who drink the most
• Health of moderate drinkers is compared to
abstainers. However, many only abstain
when already sick.
• Very few Australians are lifelong non-drinkers
and these may not be representative of the
general population.
Fillmore et al, Ann Epidemiol 2007: 17: S16-S23
Clinical Assessment
Brief questionnaires
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Sensitive and specific
Validated
Cheap, instant, quantifiable
Suitable for screening e.g. in waiting
room
• e.g.:
– CAGE and its modifications (4-6 items)1
– AUDIT (10 items) or AUDIT-C (first 3 items)2
1 Ewing, 1984, JAMA, 252
2 Babor et al, 2001, WHO
Physical examination
• Intoxication or withdrawal
• Tolerance: mild observable
impairment despite high consumption
or BAC
• Complications:
– Complete physical examination
– Remember blood pressure
• Intoxicated people can also be sick
– Remember head injury!
Assessment:
Putting it all together
• Is your patient drinking above
reduced risk levels?
• If so is he or she:
– Willing to attempt change ?
– Dependent ?
• If so, is a withdrawal syndrome likely?
• Is there organ damage or other
harm(s)?
Alcohol withdrawal scale
• Moderately useful tools (e.g. AWS, CIWA-AR)
– Objective
– Guide to treatment once diagnosis has been
made
• Limitations
– Not specific
– Inaccurate scoring is problematic
– Not validated for complex patients with
comorbidity and should not be used in that
setting
Investigations
Blood tests for alcohol use
• For recent consumption
– Blood or breath alcohol
• For “chronic” consumption
– GGT, AST, ALT
– MCV
– (CDT)
Blood alcohol (BAC)
• Detects recent drinking only
– ethanol metabolised at 10g/hour
• Breath levels correlate closely with
blood
• In a person smelling of alcohol, BAC
can
– confirm recent drinking
– suggest tolerance if high BAC, low
impairment
• Urine alcohol: longer window of
detection
GGT
(Gamma glutamyltransferase)
• The most sensitive blood test that is
widely available
– BUT only positive in 30% heavy drinkers in
community
• Alcohol is commonest cause of
elevation
– But up to 50% GGT elevation is for other
reasons inc. obesity, medications
• Half Life: 2 weeks
• Prognostic value, tool in monitoring
GGT
• More likely to be elevated if:
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Male
Obese
Long drinking history
Regular (cf episodic) drinker
>30 years
Conigrave et al, 2002, Alcoholism: Clinical and experimental research, 26(3) © Wiley 2002
Other conventional
markers
• Aminotransferases
AST:ALT >1.5 suggests alcohol
• MCV: slow return to normal
– t1/2 60 days
– Non-specific
(e.g. nutritional, drugs, liver disease)
– Increased even when folate/B12 normal
CDT
(carbohydrate deficient transferrin)
• Increase in isoforms of transferrin with lower
carbohydrate content
• t1/2 2 weeks
• Similar sensitivity to GGT, but higher
specificity
– higher levels with pregnancy, anaemia,
PBC, advanced cirrhosis
• % of total transferrin a little more accurate
• Not reimbursed by Medicare, expensive,
limited access
• Used in medico-legal settings to monitor pts
Other investigations
If indicated:
• Psychological testing: bedside or
by psychologist
• Hepatic ultrasound
• Liver biopsy – rarely
Follow-up on Mr. H
• Advised that whatever amount he is drinking, he
needs to stop
• Further history eventually elicited that for Mr H:
– 3 glasses = up to 3 x 250mls spirits daily
– Agitated if stops drinking, no tremor
• Feedback/treatment provided, including
pharmacotherapy
• Outcome at two month follow-up:
– reduced drinking to three times per week
– No further falls
– GGT fallen from 1042 to 726 U/L
– Wife: “I have a life again”
Summary
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Alcohol use disorders are common
Quantified alcohol history essential
Collateral report may be revealing
Assess dependence where clues to diagnosis
Complications affect every system, but occur
late and not in all heavy drinkers
• Laboratory tests are not sensitive enough for
screening, but may provide additional
information
Self Evaluation Question 1
Please choose the correct statement:
a) More than 80% of Australian adults used
alcohol within the last 12 months
b) Only 10% of Australians associate
alcohol with a drug problem.
c) 6.1% of the Australian population has an
alcohol use disorder.
d) All of the above
e) None of the above
Self Evaluation Question 2
Please choose the correct statement:
According to the NHMRC Guidelines,
reduced risk drinking is defined as:
a) On average, Men: no more than 4
SD/day, Women: no more than 2SD/day
with 2 alcohol free days a week
b) Men and women: 3 SD/day with 2
alcohol free days
c) Men and women: 2 SD/day or less in any
one day
d) Not drinking
e) No more than 1 SD per hour
Self Evaluation Question 3
Which one of the following is the most
sensitive indicator of chronic alcohol
consumption?
a) BAC
b) MCV
c) ALT
d) AST
e) GGT
Self Evaluation Answers
• 1: Correct answer is D.
– Yes it is a major public health
problem.
• 2: Correct answer is C.
– NHMRC advises 2SD/day or less for
healthy men and women.
• 3: Correct answer is E.
– But please revisit the slides on GGT
and remember the limitations of
GGT.
Self-test case
• Laura is a 27 year old woman who describes
herself as a social drinker.
• When you assess her further, she tells you she
goes out with her friends and tends to drink 9 mixed
drinks, 3 times per week.
• She has had episodes of being unable to
remember how she got home after an evening
drinking.
• Questions:
– What risks does Laura face from her drinking?
– What factors might encourage heavy drinking in a
young woman?
– Would you expect to see evidence of liver disease on
examination or blood tests?
Self-test case answers
• Laura runs the risks associated with acute
intoxication: e.g. sexual or physical assault, drink
driving, falls, other trauma.
• There can be peer pressure to engage in heavy
drinking from the group. Some occupations, such
as sales, where entertaining is often done over
alcohol, pose an additional risk.
• It would be surprising to see any evidence of
hepatic impairment given the episodic nature of her
drinking and her young age.
Contributors
Associate Professor Kate Conigrave
Royal Prince Alfred Hospital & University of Sydney
Dr Ken Curry
Canterbury Hospital & University of Sydney
Dr Apo Demirkol
SSWAHS Drug Health Services & University of
Sydney
Professor Paul Haber
Royal Prince Alfred Hospital & University of Sydney
Associate Professor Martin Weltman
Nepean Hospital & University of Sydney
All images used with permission, where applicable