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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5536_Библиотеки_им_академика_М_И_Перельмана.pdf
Alcohol
Citation: http://bradfordhealth.com/cms/wp-content/uploads/2014/04/cost-addiction-
treatment.jpg
Conversation starters might include:
■ Now that we have dealt with…(presenting complaint)…let’s have a look
at other areas that may contribute to your health. Are you allergic to
anything? Do you smoke? When did you last have a drink?’
■ ‘We often find that eating, smoking and drinking habits affect our health.
You did like to ask you a few questions about these things.’
Assume the patient consumes alcohol to some degree, so introduce drinking as a
normal practice, for example:
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■ ‘Most of us like to have a drink. How often would you have a drink during
the week and at the weekends?’
■ ‘Did you have a drink yesterday? What did you have, where were you,
and how long were you drinking?’
Additional aspects of a drinking history should include:
■ Pattern of consumption over past 7 days, commencing with today, and
working backwards
■ establishing pattern over a ‘typical week’, including alcohol use during
special events (e.g. anniversaries, celebrations)
■ determining whether alcohol consumption is related to cultural/religious
practices/ beliefs
2. Establish risk
Indicators of risk for alcohol-related harm include:
■ health or social problems related to alcohol use
■ concerns (self or family) about levels of consumption
■ concerns about consequences related to intoxication or high risk use, such
120
as accidents, assaults, injuries, driving offences, embarrassment related to
behaviour whilst intoxicated
■ use of other drugs (alcohol may interact with or enhance the effects of
other drugs)
■ physical trauma, possibly attributable to alcohol use
■ signs of intoxication or hangover
■ consumption regularly exceeding NHMRC guidelines for short-term high-
risk use
■ anxiety, depression, sleeping difficulties not otherwise explained
Signs and symptoms suggestive of alcohol dependence may include:
■ current intoxication (positive BAC, smell of alcohol on the breath, slurred
speech, ataxia)
■ withdrawal symptoms (tremor, sweating, agitation, anxiety, increased blood
pressure, pulse)
■ signs of liver disease (hepatomegaly, spider naevi)
Illustrated Handbook of Drugs & Alcohol Related Health Issues
Citaion: http://dualdiagnosis.org/wp-content/uploads/2014/04/Doctor-And-Patient.jpg
signs indicative of poor functioning, e.g. poor general appearance, poor hygiene
■ repeated admissions for possible alcoholrelated conditions
■ peripheral neuropathy
■ cerebellar ataxia (broad based gait)
■ cognitive dysfunction (impaired minimental examination)
■ past history (withdrawal and treatment history, periods of abstinence)
■ indicators from relevant pathology tests
Alcohol
Identify problems associated with use
■ medical
■ financial
■ legal
■ employment
■ relationships (social, work, family)
■ violence
■ psychological and psychiatric
■ sexual
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Citation: https://i0.wp.com/www.alcoholproblemsandsolutions.org/wp-content/
uploads/2015/06/Dollarphotoclub_66700484.jpg?ssl=1
Match presentation to intervention For appropriate matching of patient and intervention,
consider:
■ the patient’s wants and needs
■ ‘stage of change’
■ type and severity of problems (physical, social, emotional), and links with
problems related to intoxication, regular excessive use or dependence
■ patient safety (including other health or social risks)
Screening for Alcohol Use
Screening for disease has become a mainstay of today’s preventive health care, with
roots in medical practice that extend back to the 1930s and 1940s (1). As screening’s
effectiveness continues to be demonstrated, the demand for these assessments also
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has increased. The result is double-edged. Increased screening enables clinicians
to step in early to prevent and treat a wide range of public health problems before
they become too serious. But the time available for conducting those screens has
steadily declined. Deciding whether a particular screen is warranted, choosing the
best one for an individual patient, and administering it in a cost-effective way are
key issues for clinicians to address.
Illustrated Handbook of Drugs & Alcohol Related Health Issues
Citation: http://cbd.wpengine.netdna-cdn.com/wp-content/uploads/2015/01/520977535.jpg
Routine screening for problems with alcohol is a relatively recent practice, but has
a solid base of support. In 1990, the Institute of Medicine’s landmark report (2) on
broadening the base of alcohol and other drug abuse treatment recommended that
patients in all medical settings be screened for the full spectrum of problems that
can accompany alcohol use and, when necessary, be offered brief intervention or
referral to treatment services.
Screening is not the same as diagnostic testing, which establishes a definite diagnosis
of a disorder. Instead, screening is used to identify people who are likely to have
a disorder, as determined by their responses to certain key questions. People with
positive screening results may be advised to undergo more detailed diagnostic
testing to definitively confirm or rule out the disorder. A clinician might initiate
further assessment, provide a brief intervention, and/or arrange for clinical followup
when a screening test indicates that a patient may have a problem with alcohol (4).
There is good evidence that even patients who do not meet the criteria for alcohol
dependence or abuse, but who are drinking at levels that place them at risk for
increased problems, can be helped through screening and brief intervention (5).
Invasive Measures
Alcohol is one substance that is widely abused. Statistics show that alcoholism
or alcohol abuse is linked with almost half of all industrial accidents and half of
Alcohol
automobile fatalities in the United States. The law permits alcohol consumption,
although only to a certain extent. Alcohol testing is performed at schools, workplaces
and highways in order to ensure discipline and a safe environment.
Citation: http://i.imgur.com/fd1MQcR.jpg
123
Estimating BAC (Blood Alcohol Concentration)
A breathalyser is a reliable way to determine BAC. Breath analysis offers a good
correlation between body burden of alcohol and concentration of alcohol in
pulmonary blood circulation through measuring end-expiratory breath. Breath analysis:
■ indicates recent consumption however, cannot identify patterns of high-risk
or harmful patterns of use
■ is accurate, but expensive (a breathalyser unit needs to be purchased and
regularly calibrated)
■ results are available immediately
The term Blood Alcohol Concentration (BAC) may be used interchangeably with
Blood Alcohol Level (BAL).
Laboratory Investigations
Use of laboratory tests may assist the practitioner to relate drinking consequences
with physical sequelae, and encourage the patient to think about their drinking.
Whilst elevated biochemical markers may be indicative of liver disease, most tests
are neither sensitive or specific to both long-term or hazardous alcohol use. Liver
function tests (LFTs) provide general information about the impact of alcohol on the
body. Carbohydrate deficient transferrin (CDT) tests are more sensitive and specific
indicators of long-term high-risk use.
Most laboratory measures are less sensitive than good clinical judgment and selfreport measures, such as AUDIT and CAGE, in detecting alcohol dependence and
related health care problems
124
Illustrated Handbook of Drugs & Alcohol Related Health Issues
Non-invasive Measures
Detecting alcohol-related problems is more effective with the use of specific purpose
screening tools.
The screening tools most frequently used in Australia include:
■ AUDIT
■ CAGE
■ T-ACE
■ TWEAK
CAGE
The CAGE is a four item screening questionnaire designed to identify problem or
‘at-risk’ drinking. It can be administered as part of an interview, or as a self-report
measure, and has been successfully used across health settings, and across cultures
with minor modifications. The items are:
■ Have you ever felt you ought to Cut down on your drinking?
■ Have people Annoyed you by criticising your drinking?
■ Have you ever felt bad or Guilty about your drinking?
■ Have you ever had a drink first thing in the morning (Eye-opener) to steady
your nerves or get rid of a hangover?
Scoring ‘yes’ to two or more questions is predictive of current hazardous or harmful
drinking patterns, and indicates a need for further assessment. The CAGE has a
sensitivity and specificity of 84% and 95% respectively, and a positive predictive
value of 45% using a cut off of > 2 positive responses. But because CAGE is
considered insensitive to detection of low levels of problematic drinking the AUDIT
is considered the screening instrument of choice, given that little additional time
is required to complete, score and interpret the AUDIT.
The AUDIT
The AUDIT is a 10 item screening instrument designed to identify hazardous and
harmful alcohol consumption as well as dependence. It is easy to use, short, and
enables valuable patient feedback. The AUDIT is consistent with ICD-10 definitions
of harmful alcohol use and dependence and focuses on recent use of alcohol. It
has been validated across countries, cultures and languages (Babor & HigginsBiddle,
2001; Dawe et al., 2002).
Administration of AUDIT
The AUDIT can be administered as an interview or as a self-report measure
Alcohol
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Interpreting the AUDIT
The 10 questions are each given a score of between 0 and 4, with a maximum
overall score of 40. Whilst a single global score is considered representative of
overall drinking behaviour, examination of individual responses to each question
are important, as this will help:
■ Identify pattern of use (quantity and frequency of use, level of risk)
■ Assist in informing the type of intervention that would be appropriate (e.g.
strategies for a young person drinking infrequently but at high-risk levels
will be different to an intervention offered to an older person drinking
less, but more frequently)
■ indicate areas requiring further assessment (e.g. where the patient is showing
signs of dependence)
Citation: http://www.cehjournal.org/wp-content/uploads/The-audit-cycle.png
Brief Interventions
Health professionals are well placed to:
■ identify alcohol-related harms, and problems related to consumption or
after effects of use
■ assist patients to link patterns of consumption with current lifestyle, social
or healthrelated problems
■ provide specific, tailored interventions, that have demonstrated efficacy
within a single, or short series of consultations.
A brief intervention consisting of a short five minute session may incorporate:
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■ identification of current patterns of use, linking consumption patterns with
identified problems
■ identification of ‘stage of change’
■ assistance to assess pros and cons of current patterns of use
■ motivational interviewing techniques
■ advice on safe drinking guidelines and ways to cut down
■ provision and explanation of self-help materials e.g. drinking diaries
■ relapse prevention strategies (if relevant)
Brief interventions conducted over a short series of 2–3 sessions tend to have an
educational focus, and may include:
■ comprehensive assessment
■ specific advice
■ counselling
■ teaching goal setting strategies to assist moderating drinking patterns or
reducing harms.
Illustrated Handbook of Drugs & Alcohol Related Health Issues
Citation: https://i.ytimg.com/vi/b-ilxvHZJDc/maxresdefault.jpg
Alcohol
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ALCOHOL INTOXICATION
Alcohol intoxication is a physiological state that may also include psychological
alterations of consciousness induced by the ingestion of ethanol (alcohol). Alcohol
intoxication is the result of alcohol entering the bloodstream faster than it can be
metabolized by the liver, which breaks down the ethanol into non-intoxicating
byproducts. Some effects of alcohol intoxication (such as euphoria and lowered
social inhibitions) are central to alcohol’s desirability as a beverage and its history
as one of the world’s most widespread recreational drugs. Despite this widespread
use and alcohol’s legality in most countries, many medical sources tend to describe
any level of alcohol intoxication as a form of poisoning due to ethanol’s damaging
effects on the body in large doses; some religions consider alcohol intoxication to
be a sin.
Citation: http://images.wisegeek.com/drunk-man-with-alcohol-bottles.jpg
Symptoms of alcohol intoxication include euphoria, flushed skin, and decreased
social inhibition at lower doses, with larger doses producing progressively severe
impairments of balance, muscle coordination (ataxia), and decision-making ability
(potentially leading to violent or erratic behavior) as well as nausea or vomiting
from alcohol’s disruptive effect on the semicircular canals of the inner ear and
chemical irritation of the gastric mucosa. Sufficiently high levels of blood-borne
alcohol will cause coma and death from the depressive effects of alcohol upon
the central nervous system.
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Illustrated Handbook of Drugs & Alcohol Related Health Issues
Symptoms of Alcohol Intoxication
When consumed in large quantities in relation to the size of the person, alcohol
enters the bloodstream and causes alcohol intoxication. Indicators of alcohol
intoxication can sometimes be difficult to spot, as not everyone who drinks alcohol
will exhibit any outward signs of intoxication. Most people do show some signs of
alcohol intoxication, however, and they may included slurred speech, decreased
motor skills, sleepiness, becoming excited or hyper, becoming violent, becoming
excessively jovial or friendly, becoming dizzy, or passing out. Generally speaking,
most people exhibiting signs of alcohol intoxication will either become excessively
friendly or depressed or violent; some people may exhibit signs of both, but this
is less common.
Erratic behavior is a good indicator of alcohol intoxication. If a person is exhibiting
characteristics uncommon to his or her personality, he or she may be intoxicated.
Usually one sign of intoxication is not enough to completely indicate that a person
is drunk, but if two or more signs are present, intoxication is a strong possibility.
Erratic behavior combined with slurred speech or decreased motor skills, for example,
can indicate that a person is suffering from alcohol intoxication. A person may
become overly excited, but this does not indicate alcohol intoxication on its own.
Citation: http://images.wisegeek.com/man-with-arm-over-face-with-bottle-of-liquor-in-hand-
on-couch.jpg
Physical indicators of intoxication will also be evident. One’s eyes may become
red and bloodshot; the skin may become pale, and one may begin to stumble or
become clumsy. One may experience dry mouth and dehydration, which can cause