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Volume 19 (6) 2000
Volume 19 (5) 2000
Volume 19 (4) 2000
Volume 19 (3) 2000
Volume 19 (2) 2000
Volume 19 (1) 2000 Volume 19 (6) A message from the Chief Nursing Officer Sarah
Mullally I am delighted that this issue of the MCA newsletter recognises the nursing contribution to alcohol treatment and prevention. Nurses, midwives and health visitors have a variety of contacts with people in their homes, in hospitals, in GP surgeries, and at key points in their lives -adolescence, pregnancy, times of crisis, mean that nurses have important opportunities to influence drinking habits and identify those at risk. Alcohol is a very enjoyable part of many people's lives. But we often underestimate the harm that problem drinking can cause. 20% of general hospital beds are occupied by people with alcohol related problems and next to smoking, alcohol is the commonest addiction problem in the country. More people die each year from alcohol misuse than from illegal drug misuse. We know that alcohol is a factor in many of the priority areas in the Government's health programme -accidents, cancer, coronary heart disease and stroke, suicide and self-harm. Nurses who make the effort to ask about alcohol, who are able to share their knowledge of the risks of drinking, who know how to offer minor interventions, and who can make appropriate referrals to specialist services can make a real difference to people's lives. Nurses, midwives and health visitors also have a proactive role to play in building self-esteem and helping people make the most of life chances. Nurses work to develop communities with strong social support networks and meaningful opportunities for recreation; and develop activities which help to protect people from the risks of problem drinking. For an example, school nurses who work with young people, or health visitors who work with rough sleepers can make a real difference to the attitudes of these groups towards healthy lifestyles. Every nurse has a role, but the specialist nurses working with alcohol misuse also deserve particular support and recognition. This is why I am so pleased to welcome the launch of the Nursing Council on Alcohol in November 2000.
David
B. Cooper This issue of the MCA newsletter is a "special" for its nursing members and colleagues. This is particularly appropriate since it coincides with the launch of the Nurses Council on Alcohol. The MCA is well known for its work in increasing the profile of alcohol-related issues among the medical profession but its remit has been much broader. Nurses, midwives and health visitors have found MCA training events a valuable resource. Many members of the nursing professions value the expert advice and guidance that is freely and promptly available over the telephone from the MCA. The MCA publication Alcohol and health: a handbook for nurses, midwives and health visitors (currently under revision) has proved useful to many in the nursing professions who wanted to develop their knowledge of the field. For many years, members of the nursing professions have enjoyed the support of the MCA. Realizing that the MCA successfully helps nurses, one may question why there is a need for the Nursing Council on Alcohol. The primary responsibility of the MCA is to the medical profession, and their number is sufficient to warrant a great deal of work. This is not to undermine the work of the MCA for the nursing profession, but as the medical profession benefits from a medical approach so the nursing professions will benefit from a direct nursing approach. This is not to argue against cross disciplinary cooperation but merely to plead the need to develop understanding of alcohol related problems in the context of one's own profession in addition to the multi-profession approach. One of the first people I approached with the idea of a Nursing Council on Alcohol run along similar lines to the MCA, was Dr Peter Abraham, who was then executive director of the MCA. Typically he embraced the idea without hesitation and offered his support and encouragement. Like the MCA, the Nursing Council on Alcohol will be a UK body established to provide a forum that can offer nurses appropriate support, advice and information. The Nursing Council on Alcohol aspires to promote awareness among nurses that excessive alcohol consumption impinges on almost every aspect of health and that early identification of potential problem drinkers offers an opportunity for health promotion. The Nursing Council on Alcohol aims to aid nurses to realise their potential in this aspect of health promotion as well as how they can help individuals with more entrenched problems. The Nursing Council on Alcohol will be launched on Thursday 30 November 2000 at a conference held at the Scottish Exhibition and Conference Centre in Glasgow. I am grateful to the MCA for this opportunity to demonstrate some nursing initiatives, and for the opportunity to raise the profile of the Nursing Council on Alcohol in this newsletter.
Nursing: prevention and management of problem drinking Hazel
E Watson As the largest group of health professionals, nurses and midwives have a greater number of contacts with patients than any other member of the health care team, and in the widest range of settings. Given the widespread nature of the effects of excessive alcohol consumption, it is inevitable that nurses working in any clinical or community setting will meet people whose drinking has led directly to health problems. Therefore, irrespective of the clinical area in which they work, all nurses have a potential role to play in both the prevention and management of problem drinking. Most dependent problem drinkers seek treatment within specialist services. Within such services the staff, often working within addiction teams, are experienced and well trained in detoxification, individual intervention and group interventions. However problem drinkers often do not present themselves for treatment until their situation is compounded by advanced physical, psychological and social complications 1,2. As a result, treatment is often unsuccessful and costly in terms of specialist health service resources 3,4. General Health Services There is now convincing evidence for the high prevalence of excessive alcohol consumption amongst general hospital in-patients who are admitted for treatment of conditions that are not primarily alcohol-related 5,6. The administration of brief interventions following early detection of problem drinking has been shown to be effective and cost-effective in such settings 7. Such interventions include the provision of simple advice aimed at giving information about health risks associated with heavy drinking and about how to reduce consumption to within sensible limits. Hospital admission therefore provides nurses with an opportunity to identify potential problem drinkers and to engage them in health promotion activities aimed at achieving a reduction in levels of consumption with the consequent prevention or reduction of alcohol problems. People who are excessive drinkers present twice as frequently to general practitioners as average patients and the associated health problems contributes substantially to the workload of practice nurses, district nurses and health visitors 8,9. Although excessive alcohol consumption and its effects remain largely hidden, the financial cost to industry in the UK has been estimated at between £8 million and £14 million per annum 10. The role of occupational health nurses in promoting sensible drinking has been recognised 11, but no empirical evidence of their practice currently exists. Minimal Interventions In contrast to the specialist nature of the work of nurses in the alcohol services, it has been suggested that minimal interventions are within the scope of health care professionals who have not received specific training in substance abuse 9,12,13. General hospital and community nurses are well placed to do this, using the transferable skills, which are relevant to other aspects of health promotion, such as giving dietary and smoking cessation advice. These skills include:
The reported successes of minimal interventions have been achieved within research studies. As yet, there is little evidence of their having been adopted by nurses or doctors in everyday practice 14. Indeed nurses may well assume a role in this aspect of their everyday work, but little empirical evidence is available to confirm this. One study found that only 30% of a random sample of nurses from six general hospitals provided advice to patients whom they believed were drinking excessively, despite 88% having said that they believed this to be part of the Registered Nurses' role 15. Assessment The skills inherent in effective health promotion can be applied to the identification and management of problem drinkers. Accurate assessment of alcohol consumption is the key to detection of problem drinking. Without accurate assessment, nurses may fail to recognise problem drinkers, and opportunities for providing appropriate information may be missed. In addition, those patients whose drinking places them at risk of developing withdrawal symptoms may not be detected until serious complications become evident. Watson 15 found that, when asked to indicate the alcohol content of various beverages in standard units, only 52% of the nurses surveyed were able to identify this correctly. More recently, Burns and Adams 16 reported a study conducted in Australia in which nurses recorded an alcohol history; in over 70% of cases were judged by the project team to be accurate. However no description was given of the methods used to determine the validity of the alcohol histories. It is not known whether equivalent results would be found if the study had been carried out in the UK. Watson's findings suggest that many nurses lacked the necessary skills to enable them to calculate and record patients' alcohol consumption, thus raising questions about the basis on which advice might be given. Recognition of relative risk For nurses to use alcohol assessment in a meaningful way they require knowledge of the levels of alcohol consumption that are considered to be associated with increasing risk of harm. In Watson's survey 42% of the respondents identified the limits for sensible drinking as 21 units per week for men, and 14 units per week for women, the majority having underestimated the levels and erred on the low side. However, most possessed knowledge of alcohol-related health problems associated with prolonged heavy drinking but were less well informed about early alcohol problems. Raising Awareness In recognising relative risk, nurses should be able to identify those patients who may benefit from receiving information that can help them to reduce their drinking, and to recognise those individuals whose levels and patterns of consumption indicate alcohol dependence. In this latter situation, referral to an agency that can provide specialist help is appropriate. In order for nurses to detect and contribute to the management of problem drinkers, they need the following:
Education The contribution that nurses can make through disease prevention and the promotion of positive health has been emphasised in recent years, both from within the nursing profession and as part of the government's political agenda. The United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC), the regulatory body for nursing and midwifery within the UK, has endorsed this stance by ensuring that the promotion, restoration and maintenance of health were central themes of the curriculum which was introduced at the end of the 1980s, and which has recently been rigorously reviewed 17. However, although health promotion, as a topic, is now addressed, alcohol may not be given appropriate emphasis. In addition, because the effects of excessive alcohol consumption are so widespread, they are referred to as part of the pathology of many disease processes, rather than as an entity in its own right. It is, therefore, possible that no coherent approach to the prevention and management of alcohol problems per se is taken. The English National Board, which has delegated authority from the UKCC to ensure the implementation of the UKCC's standards in England, undertook a substance misuse training needs analysis in 1995 and recommended that alcohol-related health issues be integrated throughout all nursing pre-registration programmes. The extent to which this has been achieved has not been systematically examined. Administration of minimal interventions depends on knowledge of the levels at which drinking is likely to become harmful, as well as knowledge of the nature of advice to be given. Drummond 18 has cautioned against widespread implementation of brief intervention strategies, arguing that if the interventions were delivered by practitioners who do not have the appropriate knowledge and motivation, the interventions could be ineffective or, at worst, harmful. It is therefore essential that nursing staff should be well informed and educationally prepared in the necessary techniques. Resources Coinciding with the UKCC's educational reforms were those of the NHS, which brought demands for increased efficiency and cost-saving measures. The resultant increase in management responsibilities for clinical nurses and shorter episodes of care for hospital in-patients, who generally more seriously ill, has meant that time for reflection on lifestyle issues may have been eroded by more pressing demands on the time available to nurses. It is important that relevant health education leaflets, such as the HEA's 'That's the Limit' are available at ward level for nurses to pass on to patients. Attitudes There may be reluctance on the part of nurses to take a drinking history from patients because they may feel that patients might be offended. The accuracy of the alcohol history is likely to be enhanced if patients are asked about their drinking in a sensitive but matter-of-fact way. Questions about drinking may be asked together with those on other lifestyle factors, such as diet, exercise and smoking as part of routine procedures on admission to hospital or when attending clinics at health centres or the GP surgery. Attitudes are conditioned by people's experiences. Patients who are intoxicated or experiencing alcohol withdrawal can be difficult to manage and may be verbally or physically abusive. Consequently, it may be that some nurses have acquired negative attitudes to problem drinkers, which may reduce their willingness to assume a preventative role. Furthermore, they may subscribe to the view that all problem drinkers are unable or unwilling to change their drinking behaviour, and consequently not address the issue. Conclusion While nurses undoubtedly have opportunities to work with problem drinkers, it is not certain whether the entire profession has embraced this as wholeheartedly as they might. Further survey work is required to determine this. A range of factors may be working together to prevent them from being as active as they might be in this area. However, might the same not be said for all others within the multidisciplinary health team? References
2000 Volume 19 (5) ALCOHOL AND THE GASTROINTESTINAL TRACT: AN OVERVIEW By Dr. J. S. R. Jennings, Clinical Research Fellow and Professor P. D. Howdle, Professor of Clinical Education & Consultant Gastroenterologist, Division of Medicine, St. James's University Hospital, LEEDS LS9 7TF Alcohol is a significant toxin within the gastrointestinal system. In the liver it may cause inflammation, cirrhosis and hepatocellular carcinoma. In the pancreas it may cause inflammation and a loss of exocrine function leading to malabsorption. These conditions have been extensively reviewed in the established medical texts. This article will concentrate on the remainder of the gastrointestinal tract.
The Mouth Alcohol causes mucosal trauma, predisposes to Candida spp. infections, and promotes pre-malignant i.e. leukoplakia and malignant change. Interestingly malignancy may develop several years after abstaining from heavy alcohol consumption. It may also occur at multiple primary sites. This suggests that a dysplastic "field change" in the oral mucosa develops prior to frank squamous cell carcinoma. Unfortunately no prevalence data exists for oral malignancy in chronic alcoholism, other than to say it is believed to be rare. Salivary gland enlargement, especially involving the parotids, is well described in alcoholics. Indeed, this contributes to the characteristic alcoholic facies. Several studies have demonstrated evidence of increased periodontal disease and dental caries in alcoholic patients. The Oesophagus Gastro-oesophageal reflux disease, oesophageal dysfunction and malignancy are all associated with excess alcohol intake. Alcohol increases mucosal permeability to H+ ions and susceptibility to acid-pepsin damage. The mucosal barrier function is thus impaired. Alcohol disables the lower oesophageal sphincter mechanism and decreases luminal clearance. These pathophysiological effects vary according to the duration of alcohol abuse. In bingers symptomatic dyspepsia develops due to a decrease in the lower oesophageal sphincter pressure and in the amplitude of oesophageal peristaltic contractions. These revert to normal between 8 and 24 hours later. Interestingly these changes also occur in chronic alcohol consumers while they continue to drink, but are reversible in the majority. Only in chronic alcoholics with evidence of peripheral neuropathy do these oesophageal changes become permanent. In this latter group symptoms may be entirely absent or they may suffer severe acid reflux, dysphagia, nausea, vomiting and retching. In contrast during acute alcohol withdrawal the lower oesophageal sphincter pressure and peristalsis are increased. The clinical significance of this is not clear. Alcohol and tobacco smoking have a synergistic action in causing oesophageal malignancy. Classically alcohol is associated with squamous cell carcinoma of the oesophagus. Epidemiological evidence proposes that 95% of the malignancies are due to smoking and alcohol (in USA and Northern Europe). It has been suggested that a daily consumption of greater than 80g of ethanol and 20 cigarettes increases this cancer risk 50 fold. The risk appears to be dose responsive. Furthermore the type of alcohol may also influence this risk. Typically spirits are implicated. An example of this has been cited in an Afro-Caribbean population in South Carolina, USA where high levels of malignancy were linked to moonshine. Of course it is possible that this effect may be due to other co-carcinogens that are present in the alcoholic beverage. The Mallory Weiss tear is a linear mucosal tear near the gastro-oesophageal junction either in the distal oesophagus or proximal stomach. It is responsible for up to 30% of upper gastrointestinal haematemeses. Repeated vomiting or retching due to alcoholism is its most frequently associated feature and cause. The Stomach Alcohol has numerous actions on the stomach and gastric mucosa. It stimulates acid and gastrin production. Modest alcohol consumption may protect against Helicobacter pylori. In larger doses alcohol damages the mucosal barrier. Alcohol induced gastritis with nausea, vomiting and retching occurs in over 80% of dependent alcoholics. The histology is characterised by subepithelial haemorrhages and oedema. There is relatively little inflammation. The relationship of alcohol to the development of peptic ulceration is not completely established. Mucosal injury does not occur at gastric ethanol concentrations of under 10%. In fact low levels of consumption may be protective. At gastric concentrations above 20% then endoscopic evidence of mucosal injury is seen. In population studies the prevalence of peptic ulcers is lower in modest drinkers compared with non-drinkers. The only clear positive association between ethanol intake and ulcer disease exists in patients with portal hypertension due to established cirrhosis. In such a situation haematemesis may occur due to varices, peptic ulcers, a Mallory Weiss tear or portal gastropathy. This produces an erythematous reticular or mosaic pattern on the gastric mucosa which may bleed spontaneously. Binge drinkers put themselves at risk of gastric mucosal erosions which can bleed torrentially, particularly in view of the evidence that alcohol in high concentration can cause haemorrhagic gastritis in animal models. Gastric carcinoma is thought to develop as a result of alcohol induced mucosal damage and dysplastic change. Similar to oesophageal carcinoma, smoking is also suggested as a significant co-factor. However, in this case the epidemiological evidence is poor. The Small Bowel Damage to the small bowel mucosa is common in chronic alcoholics. Even in asymptomatic individuals it can be detected using sensitive intestinal permeability tests. Impaired mucosal barrier function allows increased permeability to intestinal toxins and bacteria. This contributes to mucosal inflammation - " alcoholic enteropathy". Intestinal villous blunting may occur due direct cytotoxic effects of alcohol on enterocytes and crypt cells. This can cause impairment of the mucosal brush border and loss of the luminal disaccharidases which are involved in digestion. Alcohol causes increased gut motility and transit times. Mucosal damage impairs salt and water absorption. Alcohol inhibits the absorption of vitamins and nutrients that require active processes. Biliary secretion and re-absorption are diminished. Many of these defects are confounded by co-existing nutritional deficiencies which directly influence mucosal health and assist in absorption, e.g. folate and zinc. These combined pathologies lead to a failure in the digestive process and a malabsorptive state. Further problems result from the impaired permeability barrier, since nutrients can leak from blood and tissue out into the gut lumen. There are numerous symptoms which result from alcohol-induced damage to the small bowel. These include diarrhoea, generalised malnutrition and the specific disease states that may arise from specific nutritional deficiencies. Interestingly many of these effects are reversed if the patient consumes a normal diet even if some alcohol consumption continues. Sadly, the diet of a chronic alcoholic is characteristically poor. It is important to consider the effects of alcohol on the pancreas when discussing small bowel disease. Malabsorption is all too often the result of the failure of pancreatic exocrine function. Clinically the result is the same; however it is useful therapeutically to consider pancreatic supplements such as Creon. The Colon Colonic diarrhoea can occur due to two mechanisms. First direct mucosal damage from alcohol leads to impaired salt and water re-absorption. Secondly an increased gut transit time means that toxins normally confined to the small bowel can irritate and inflame the more sensitive colonic mucosa. There is evidence for a 10-fold increased risk of colonic malignancy in chronic alcoholics. Again smoking is an important co-factor. Alcohol and Gastrointestinal Cancer - Proposed Mechanisms Epidemiological evidence suggests that alcohol is a significant risk factor for malignancies involving the oropharynx, larynx, oesophagus and liver. Smaller risk associations are seen with breast and colon cancer. However, this small risk is more significant in terms of population as these two latter cancers are so common. The link with gastric neoplasm is not clearly established. Interestingly animal models of these diseases suggest that alcohol may not be a primary carcinogen but rather an important co-carcinogen. Alcohol impairs the immune system and leads to important nutritional deficiencies, e.g. the cancer protective antioxidants. Molecular studies have begun to unravel how alcohol may act in carcinogenesis:
Summary The effects of alcohol on the GI tract are not normally to the fore in the consideration of gastrointestinal disease. However it is important to remember that in the causation of gastro-oesophageal reflux disease, gastritis, diarrhoea and malabsorption, as well as in a number of GI malignancies, alcohol plays a significant role. References
DR PETER ABRAHAM, EXECUTIVE DIRECTOR, MCA, 1992-2000 Having successfully seen the Medical Council on Alcohol, into a new century, Dr Peter Abraham is retiring after 8 years as our Executive Director. During the period, he has contributed enormously to the growth and development of the Council. Membership and activities have all increased significantly. Our range of high quality publications has been extended. In addition to the tangible products of the MCA, the Executive Director has also been a source of informed comment on the enquiries about medical aspects of alcohol related problems which come on a daily basis. Recently, he has augmented this information by creating the MCA website. New alliances have been formed with other organisations and old friendships strengthened. Peter came to us from a distinguished career as Senior Psychiatrist and Professor of Psychiatry in the Armed Forces. On arriving at the Council, he quickly turned his energies to the task of undergraduate and post graduate education in alcohol and health which is often woefully lacking in medical and nursing schools. He has worked hard to improve the funding base of the Council without which it will not be able to carry out an ever increasing range of tasks. His enthusiasm, energy and attention to detail will be greatly missed by all the colleagues and agencies with which he worked. I know that all members of the MCA wish him and his wife well for what will doubtless be an equally energetic and active retirement. Bruce Ritson, Chairman, MCA
THE WERNICKE-KORSAKOFF SYNDROME CAN BE TREATED Professor
C.C.H. Cook and Allan D. Thomson What could possibly be new about Wernicke's Encephalopathy at the beginning of the 2lst century when its pathology was described by Karl Wernicke, a Polish neurologist in 1881? After 119 years of unprecedented medical progress, many patients are still unnecessarily developing brain damage and that the incidence of irreversible brain injury Korsakoff's Psychosis is probably increasing in the U.K. This situation has occurred in part because new knowledge about the condition obtained in the last few years is not widely known by clinicians treating these patients. Furthermore some older but crucial information has been forgotten by many doctors, causing their treatment to be sadly inadequate at times. Sometimes litigation follows. The Wernicke-Korsakoff Syndrome is caused by an inadequate supply of thiamine (Vitamin B1) to the brain and is a condition found in heavy drinkers. It can also occur in any circumstances of sufficient nutritional deprivation, even when alcohol is not involved, e.g. hyperemesis gravidarum. Acute severe thiamine deficiency results in Wernicke's Encephalopathy which is classically described as having an acute onset with:
It has become clear in recent years that only 10% of patients have the classic triad of signs and that the diagnosis is frequently missed. Inadequate treatment of Wernicke's Encephalopathy results in Korsakoff's Psychosis, characterised by severe short-term memory loss, and patients may need costly long-term residential care. Because of the close relationship between the two conditions, reference is often made to Wernicke Korsakoff Syndrome as if it were a single entity (Figure 1).
Contrary to general belief, Wernicke's Encephalopathy is a common condition although it is not often diagnosed until after death. Much of our understanding of the natural history of the disease is due to Victor and Adams in the USA. Subsequently, Harper in Australia and other workers in Europe employing careful histological techniques have shown that damage to Wernicke's area of the brain can be found in 1.5% of all post-mortem examinations carried out in general hospitals. This prevalence increases to 12.5% in alcoholic patients and to 30% if cerebellar damage due to thiamine deficiency is included. Less than 20% of patients are diagnosed prior to post-mortem. Difficulties with diagnosis are compounded by the fact that fewer patients are treated in specialised units by experienced staff. Patients often present to accident and emergency departments, all specialties of Medicine, Surgery, Obstetrics and, not least, General Practitioners. Many patients remain inadequately treated. Added to this problem is the confusion that exists about the amount of thiamine to be given, the route of administration and duration of treatment. It is clear that guidelines for treatment are urgently required and all members of staff involved in treating these patients will need to be familiar with them. Pathogenesis Thiamine depletion is common in alcoholic patients because of reduced intake, malabsorption, reduced storage and impaired utilization. Thiamine can be obtained from a number of sources (figure 2) and in many countries bread is supplemented with thiamine (figure 3).
Heavy drinkers often substitute alcohol for food. Vomiting due to gastritis or diarrhoea/steatorrhoea further reduce nutrient supplies. The ability to absorb thiamine hydrochloride can be markedly reduced by the effects of malnutrition or alcohol which may independently interfere with the active transport of thiamine across the intestine. Consequently some patients develop Wernicke's Encephalopathy, even while taking oral multi-vitamins, and replacement thiamine must be given parenterally. Confused patients admitted to hospital are frequently given intravenous glucose infusions which increase thiamine requirements and may precipitate or exacerbate Wernicke's Encephalopathy. In the early stages of Wernicke's Encephalopathy a "biochemical lesion" exists which probably results from an inhibition of carbohydrate metabolism dependent upon thiamine acting as a co-enzyme. Prompt treatment at this stage is most successful. As structural damage develops, the response to therapy becomes less and ultimately irreversible damage leads to Korsakoff's Psychosis. The lack of ability to create new memories leaves previously highly skilled individuals unable to remember people or events which have occurred only moments before, thereby rendering them severely disabled. Diagnosis The consequences of missing a diagnosis of Wernicke's Encephalopathy are potentially serious indeed. Therefore a presumptive diagnosis of Wernicke's Encephalopathy should be made in any patient with a history of alcohol misuse who shows evidence of ophthalmoplegia, ataxia, acute confusion, memory disturbance, unexplained hypotension, hypothermia, coma or unconsciousness. Patients often present to busy accident and emergency departments where the workload is high, patients have often been drinking alcohol, there may be confusion about the appropriate treatment and there are no ready means of quick assessment or agreed guidelines. Indeed, half of the patients with head injuries are heavy drinkers and are often not given parenteral vitamins. Unless we take a more pro-active approach to patients at risk, 20% of patients with Wernicke's Encephalopathy will continue to die and only 10% will make a good recovery. 75% will be left with permanent Korsakoff's psychosis of whom 25% will require long-term institutionalization. Increasingly such cases have become the subject of litigation with damages in the order of £0.5 million or more. Treatment Patients who have developed signs of a presumptive diagnosis of Wernicke's Encephalopathy should be treated empirically with B-complex vitamins. Two pairs of intravenous or intramuscular high potency parenteral B-complex vitamins three times daily should be given for at least two days. Where an effective response occurs, one pair of intravenous or intramuscular ampoules should be continued once daily for five days. Prevention
The estimate of the dose of thiamine required to prevent or treat Wernicke's Encephalopathy is largely based on data from uncontrolled trials or empirical clinical practice. The dose required is probably in excess of 500 mgs. of thiamine once or twice daily for 3-5 days. This regime produces a sustained high blood concentration of thiamine which is adequate to overcome the rate-limited transport into the brain, allowing repletion by diffusion. Patients with beri-beri respond to much smaller doses of thiamine, suggesting that in the alcoholic patient the thiamine dependent enzymes of the brain, required to meet its enormous energy needs, may have been partially damaged by acetaldehyde and free radicals from alcohol metabolism. The damaged apoenzyme then requires higher concentration of thiamine to function. Repeated parenteral doses are needed because of the rapid urinary excretion of thiamine. Although the frequency of adverse reactions is low, it is important to recognise that there is still a significant risk of serious reactions and that B-complex vitamins should therefore only be administered in circumstances where cardio-pulmonary resuscitation can be offered if necessary. It is recommended that when given intravenously, parenteral B-complex vitamins should be administered by slow infusion over 10 minutes or more and should be diluted with 50-100 mls of normal saline or 5% dextrose. Why did practice change? For many years, thiamine replacement was given parenterally for the prevention or treatment of Wernicke's Encephalopathy. This practice changed in the United Kingdom after a report by the Committee on the Safety of Medicine in 1989 warning of the risk of serious allergic reactions following the administration of parenteral B vitamins (Parentrovite). The recommendations were based on 90 reports of adverse reactions (72 associated with intravenous administration and 18 with intramuscular administration) between 1970 and 1988. During this period between half and one million pairs of ampoules of each preparation were sold annually, suggesting four reports of anaphylactoid reaction for every one million pairs of intravenous ampoules, or one report for every five million pairs of intramuscular ampoules used. This incidence of adverse reactions is low in comparison to other drugs in common use (e.g. penicillin, streptokinase). The benefit:risk ratio still clearly lies in favour of B-complex vitamins. However, many clinicians turned to inadequate oral therapy for prophylaxis and treatment of Wernicke's Encephalopathy in the UK, although parenteral use continued in other countries. The problem became more complicated when difficulties in manufacture of Parentrovite led to withdrawal of this product in 1992. The currently available intravenous product, Pabrinex, was introduced nine months later and the intramuscular preparation followed one month after that. A recent survey of physicians in accident and emergency departments has shown that there is a wide variation in the current practice and that oral administration was favoured unless definite signs of Wernicke's Encephalopathy were seen. Vitamin deficiency is also perceived as uncommon in alcohol misusers and there was no consensus as to which B vitamins might be beneficial. Prophylaxis There is no published evidence of how patients should be selected for prophylaxis. It could be offered to all in-patients undergoing alcohol withdrawal. This would include patients initially admitted for other reasons but subsequently requiring detoxification. One pair of intramuscular high potency parenteral B-complex vitamins once daily for 3-5 days is recommended. Outpatient and Community Treatment If we assume that patients with a probable diagnosis of Wernicke's Encephalopathy or other serious complications of alcohol withdrawal would be admitted to hospital, then patients treated in the community would be at low risk of Wernicke's Encephalopathy. The options for their treatment would be:
Conclusion Wernicke-Korsakoff Syndrome is a common condition with a high morbidity and mortality. Oral vitamin supplementation is ineffective while the serious side-effects of parenteral therapy are relatively rare. There should be a low threshold for making a presumptive diagnosis of Wernicke's Encephalopathy and all in-patients undergoing alcohol withdrawal should be offered prophylactic treatment with parenteral B-complex vitamins. Further Reading
Declaration of Interest This article was in part based on a recent symposium (published in a Supplement to Alcohol and Alcoholism Vol 35) which was supported by an unrestricted educational grant from Link pharmaceuticals.
Doctors need to be informed about the whole range of alcohol misuse, not just the medical aspects Alex Paton, Retired Consultant Physician, Oxfordshire At the end of the 1970s, after 20 years of trying unsuccessfully to rescue patients with livers damaged by heavy drinking it dawned on me that there might be better ways of tackling the problem. Rather than try to repair the damage would it not be preferable to intervene early and prevent damage by helping at the stage where people were starting to have problems? The idea seems obvious but who should do it? Some of my colleagues felt that this was not a job for doctors. Formation
of Alcohol Concern and the MCA Not
just a medical problem Training
of doctors Multidisciplinary
teams Speed
of response A final hope of mine is that drug and alcohol agencies will eventually be amalgamated. Where this arrangement has been tried it seems to work well. Pragmatically it would be an advantage at a time when drug misuse services are well funded but alcohol misuse services are short of resources. I would go further and treat all addictions including tobacco, alcohol, drugs, gambling, sex, exercise and computer games in a single unit. In this way the management of alcohol misuse would not be a Cinderella service to be cosseted by kindly but reluctant psychiatrists or gastroenterologists, but would take its place as of right in a department of addiction medicine, a speciality which already flourishes in the United States. References
Sharpening Surgical Skill : The Effect of Alcohol and Sleep Deprivation on Surgical Dexterity By
Simon Smith, Nick Taffinder, Tim Brown and Ara Darzi Introduction Mr Simon Smith gave the annual MCA lecture at the Annual General meeting of the MCA held in the Royal College of Physicians on 25th November 1999. This article describes the work presented in that lecture. The MCA together with the Alcohol Education Research Council has contributed to the funding of this research project. The Pressure to Change The training of surgeons has traditionally been an apprenticeship. Trainees learn to undertake surgical procedures by first observing, next assisting, then performing under supervision and finally performing alone. This is an efficient and safe method provided it is properly supervised, but there may be some skills that are better learnt in the training laboratory rather than in the operating theatre. The advent of minimal access or laparoscopic surgery has given particularly strong impetus to the development of new training and assessment methods. Minimal access surgery demands high dexterity and novel skills from the surgeon. Particularly important are the abilities to operate in a 3-dimensional environment whilst observing just a 2-dimensional image and to operate using very long tools, without the normal tactile feedback from hands and arms received when performing open surgery. Other pressures have also increased the need for the development of better methods of training and assessing surgeons. Shorter training as a result of the Calman Report has resulted in the development of courses to train core skills for both basic and higher surgical trainees. Political pressure in the aftermath of the Bristol Children's Hospital Inquiry [1], has heightened the need for reliable and valid ways of training surgeons, both in and out of the operating theatre. Assessment is a key part of training, but finding valid and objective methods of assessing surgical performance has so far proved to be difficult. The assessment of surgical performance and skill has grown to be a major focus of research within our department at Imperial College and within departments at several other medical schools. Assessing Laparoscopic Dexterity The surgical accreditation process includes extensive examination of many areas of knowledge, but practical aspects, particularly dexterity, remain un-assessed amongst the majority of surgeons. At Imperial College we have developed a computer based system to assist with the assessment of surgical dexterity. Dexterity is only one of many skills that a surgeon needs to perform safe and competent surgery and surgery is said to be 75% decision making and 25% dexterity [2]. Initially our work looked at motion analysis as a measure of dexterity, whilst performing a computer based simulation of laparoscopic surgery [3]. Mechanical tracking devices collect data on the position of the simulated tools as a task is performed and this data is analysed by a custom built software package. This combination of hardware and software which has been named the Imperial College Surgical Assessment Device produces data from which speed and accuracy of movement can be derived. Adapted mechanical tracking devices, allow the movements of surgeons to be analysed as they perform simple physical simulations of real laparoscopic surgery, such as pulling and cutting pieces of thread. The measures produced appear to be valid reflections of laparoscopic skill and can show differences between experienced and less experienced surgeons.[4]. New developments allow tracking systems to be used on surgeons performing real surgical procedures in the operating theatre so that direct comparison can be made between simulated and real operative surgery The Effect of Alcohol Alcohol misuse amongst the medical profession is well documented. Some reports suggest as many as 42% of health workers admit to having turned up for work hungover [5]. Whilst common sense suggests that performance in either intoxicated or hungover states might be impaired, there is little data on how surgical performance is affected by alcohol. Pilots have a 'bottle to throttle' time, but there are no such rules for surgeons . The advent of training and assessment tools such as the Imperial College Surgical Assessment Device provides some objective methods with which to measure the decrement in skill following alcohol ingestion. Such tools might provide evidence on which to base policies for safe drinking practice, including limits of amount and time between alcohol and surgery. Our study has looked at the effect of alcohol on simulated laparoscopic task performance in a group of trainee surgeons and students, all of whom were familiar with laparoscopic techniques. In order to minimise training and cognitive effects all twelve subjects trained extensively on the simulations before the study. Subjects were randomised into a two by two crossover trial. On different occasions each subject would be given either a full alcohol dose in orange juice (alcohol 0.8 g/kg) or as placebo orange juice on to which a very small amount of alcohol had been layered (alcohol 0.1g/kg). The full dose was intended to produce a blood alcohol level similar to that of the legal limit for driving limit. The crossover design allowed within subjects analysis and controlled for learning. On each occasion, subjects were tested before drinking, and then for eight hours after ingestion of the full dose or placebo. The subjects were tested on a virtual reality simulator (MIST VR, Virtual Presence UK), and while performing tasks within a standard closed box laparoscopic training device. Performance on each task at each test occasion was monitored using the Imperial College Surgical Assessment Device. Blood alcohol level at each test time was assessed using a breath alcohol device (AlcometerII, Lion Laboratories, Barry) which was recalibrated on each trial day. Results show trends across many measures of dexterity in the acute phase of alcohol intoxication. In the full dose group the only significant impairment of virtual task performance was prolonged time to undertake a simulated diathermy task (making a precise burn on a target at a distance) one hour after ingestion when mean blood alcohol concentration was 77.9 +/- 8.1 mg/dl. Impaired learning with reduced efficiency of movement could also be seen and this lasted as long as six hours after ingestion. Assessment of performance on real surgical tasks shows more dramatic effects, particularly on the learning curve. Although all subjects had been extensively pre-trained on the systems, the placebo group showed improving efficiency of movement with repeated performance of the tests over eight hours on the same day. However, the full dose alcohol group did not show this learning effect. Although there was some recovery from the initial detriment in performance, significant differences in several aspects persist six hours or more after reaching a peak level of less than 80 mg/dl. This effect is seen particularly in performance scores for left handed tasks (all subjects were right handed), in terms of both distance traveled and number of movements made to complete the task. The results are of importance and especially so for surgeons in training. Impaired learning is still seen six hours after ingestion of alcohol. If a detriment in learning can be demonstrated as long after reaching a level similar to the legal driving limit as this, then more excessive drinking might impair performance and particularly learning for longer periods. Whilst no one would condone being intoxicated with alcohol when on duty, few people consider it necessary to avoid alcohol the night before operating. Further studies might be specifically aimed at the effect of hangover, with the aim of defining safe 'bottle to theatre' times. Sleep Deprivation The cognitive and psychomotor impairments incurred by sleep deprivation have been well documented outside the medical field, and some studies have been made of doctors working in medical specialties [6]. However although surgeons are often experience sleep deprivation or disturbed sleep no studies have been made of the effects of abnormal sleep patterns on surgical performance. Six surgeons were entered into a six by six cross over trial, designed in a Latin Square. Each subject spent two nights in each of three sleep conditions: i) A full night's sleep. ii) A night where subjects were allowed to sleep, but were woken every three hours, kept awake for 15 minutes, then allowed to return to sleep, and iii) A night where subjects were kept up and awake all night. Their performance was tested using the virtual reality simulator on the evening before, and the morning after the study night. Subjects make significantly more errors in performing tasks and take more time after sleep deprivation. Sleep deprived groups also show increases in stress and decreases in arousal (as measured with questionnaires) [7]. This study has shown impaired performance produced by both disturbed and absent sleep as assessed on surgical simulators. The relevance of this to clinical outcome is unclear until it is decided how closely such laboratory based trial using a simulator parallels real clinical practice. However, policy on working hours and sleep patterns might well be influenced by such studies. Conclusion Simulators and objective tools for the assessment of surgical skill have been developed and could be used in training and accreditation of surgeons. Their role in assessing performance under differing environmental conditions has yet to be fully exploited. The optimal conditions under which a surgeon should work are far from clear. Our studies suggest that surgical performance can be impaired both by alcohol and by sleep deprivation. Appropriate policies on hours of sleep and consumption of alcohol might lead to improved performance by the surgeon and improved surgery for the patient.
Employment, Unemployment and Drinking By John Kemm, Welsh Combined Centres for Public Health, Cardiff High Risk Occupations It has long been recognised that those working in some occupations are more likely to be heavy drinkers than those working in other occupations. Death rates for chronic liver disease (a high proportion of which is alcohol related) vary between occupations. In the past doctors shared with publicans and barstaff, seafarers and lawyers the characteristic of having high proportional mortality rates for cirrhosis and other alcohol related disease [1]. However more recent information on drinking taken from the General Household Survey suggests that doctors are no longer an occupation in which heavy drinking is particularly prevalent. [2] Several factors may increase the risk of heavy drinking in a particular occupation. Access to alcohol and lack of supervision are features of many high risk jobs as is a culture of drinking in work settings with customers or work colleagues. Long hours of work, stress and lack of support are often claimed to be predisposing factors but these are not the exclusive preserve of high risk professions. The possibility that whose psychological characteristics places them at high risk of alcohol related problems might be attracted to certain occupations cannot be excluded. Unemployment If heavy drinking is associated with certain occupations it is also associated with unemployment. Numerous surveys have shown that both abstention and heavy drinking are more common among the unemployed than among the employed [3]. Aimlessness, lack of structure for the day and loss of self esteem may all predispose to increased drinking and the need to replace work social networks may draw people to the pub. On the other hand economic studies show that alcohol purchases are income sensitive and that when their income falls people tend to buy less alcohol. This may lead people to reduce consumption when they become unemployed. The association of heavy drinking and unemployment could reflect a causal connection between lack of job and drinking or vice versa. Data from the Regional Heart Survey [4] showed that heavy drinkers were more at risk of subsequent unemployment and that on becoming unemployed most people tended to decrease their alcohol consumption although a few increased it. There is a temptation to rush in with explanations for assumed behaviour patterns before the patterns that one is trying to explain are clear. Undoubtedly the associations between occupation, unemployment and drinking behaviour are complex. Most of the studies have concerned men and more data is needed on women particularly now that women constitute a much large proportion of the paid workforce. References 1. Coggon D, Inskip H, Winter P, Pannett B (1995) Occupational mortality of men In Occupational Health: Decennial Supplement Series DS10 London HMSO 2. Elliott R (1995) Smoking, drinking and occupation. In Occupational Health: Decennial Supplement Series DS10 London HMSO 3.Lee AJ, Crombie IK, Smith WCS, Tunstall-Pedoe H (1990) Alcohol consumption and unemployment among men: Scottish Heart Health Study. British Journal of Addiction 85, 1165-1170. 4. Morris JK, Cook DG, Shaper AG. (1992) Non employment and changes in smoking, drinking and body weight. BMJ 304, 536-541.
The Leeds Forgiveness for Addiction Recovery Project Dr. Ken Hart, School of Psychology, University of Leeds, LS2 9JT Persistent anger, resentment and the desire for revenge represent serious handicaps that hinder the likelihood of treatment success for people receiving treatment for alcoholism and other addictions. A growing body of scientific evidence suggests forgiveness may be the key to unlocking the chains that bind people to past hurts. Forgiveness is not giving in to another person or condoning or denying what they have done. Nor is it staying in abusive relationships. Forgiveness is about achieving the two components of serenity; peace of mind and peace with those around you. A research team in the University of Leeds has received a grant of $120,000 to test the theory that forgiveness can be taught like any other skill. The programmes Two different training programmes are being tested. The two treatments are expected to help addicts in recovery let go the burden of pain from the past that they carry. The first programme uses a secular approach to foster empathy. Participants will be helped to better understand the imperfections in the people towards whom they harbour ill will and to learn that the bestowing forgiveness is like a gift in that it is given and does not have to be earned. It is important to understand that while forgiveness is always desirable, reconciliation may not always be so. The second type of 'forgiveness therapy' being tested is a spiritually based 12 step facilitation based on the therapy successfully used by Project MATCH in the USA. Recovering addicts who have harmed others will be encouraged to apologise for wrongdoing and make restitution. Seeking forgiveness requires humility and the assistance of a Higher Power helps people transcend their Ego which normally balks when asked to admit mistakes. The study Training of counsellors in how to administer forgiveness therapy began in December and those who satisfactorily complete training will be awarded a diploma. Then over a five month period the counsellors will lead ten two hour forgiveness group therapy sessions. During this period they will conduct personalised client follow ups and receive supervison from project staff. It is intended that ninety six members of 12 step fellowships will receive instruction in how to give and receive forgiveness. They will also have their emotional, interpersonal, medical and spiritual health assessed before and after they participate. The study will be based in London and the project team has developed partners with several treatment centres where the sessions will take place. Opportunities are still available for other centres to become partner centres and link with the project Although the first client sessions are scheduled to begin in February 2000 but the research team is still looking for counsellors and for participants. Counsellors are not paid for attending training but they receive a diploma on satisfactory completion and training is free. Counsellors are paid by the project for running the forgiveness group therapy sessions. Further information can be obtained from the author phone 0113 233 5755 or on Web site http://www.psyc.leeds.ac.uk/research/hlth/farp.
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