Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Forgetting the evidence
- Joss Bray (1 March 2008)
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First Do No Harm
- Andrew J Ashworth (2 March 2008)
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Alcohol abuse in adolescents
- Kelsey D J Jones, David Porter, Huw Williams (4 March 2008)
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Prescription of Benzodiazepines for Alcohol Detoxification: Cons as well as Pros
- Neil R Wright, Caroline S Cooper (5 March 2008)
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Re: Forgetting the evidence
- Robin Touquet (5 March 2008)
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Re: Re: Forgetting the evidence
- Joss Bray (7 March 2008)
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Joss Bray, Substance Misuse Specialist Sunderland
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I would just like to point out that although there are firm recommendations given in this article on Thiamine supplementation for the prophylaxis and treatment of Wernicke's syndrome, there appears to be no convincing evidence base upon which to make these statements. The Cochrane review in 2004 by Day, Bentham, Callaghan, Kuruvilla and George stated that "There is therefore insufficient evidence from randomized controlled clinical trials to guide clinicians in the dose, frequency, route or duration of Thiamine treatment for prophylaxis against or treatment of WKS (Wernicke Korsakoff Syndrome) due to alcohol abuse". Although it has long been practice to inject people with Thiamine when having an alcohol detox, perhaps we should look again at the guidance since the treatment is not without risk (anaphylaxis, pain) and cost (time required by staff to draw up, administer and monitor being the principal factors as well as drug and equipment costs). I can see the arguments for parenteral administration because of poor oral absorbtion, but there are many more factors involved which don't appear to have been studied enough to make dogmatic recommendations at this stage. Treatment should be either evidence based or not - and we should be clear about which it is before accepting guidance without question. Dr Joss Bray Competing interests: None declared |
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Andrew J Ashworth, GP Davidsons Mains Medical Centre, Edinburgh, EH4 5BP
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In what other context than Substance Misuse would the following summary of the evidence: “Three drugs are commonly used to prevent recurrence of this condition — Drug A is an effective component of strategies to prevent recurrence. However, it is not risk free, and is contraindicated in people with cardiovascular disease, hypertension, pregnancy, or a history of cerebrovascular accident or psychosis. Drugs B & C are much safer than Drug A, but Drug C is unlicensed in the UK for this indication. Although most randomised controlled trials show a positive effect, the effect size is small and outcomes vary greatly.” Have led to the recommendation that “These three drugs should routinely be considered as adjuncts to psychosocial programmes and self help groups, to enhance the effectiveness of treatment.”? Those with drink problems are notoriously frustrating to manage and are at considerable risk of physical as well as psychological harm: where the balance of risk and benefit favours risk, it is generally better not to prescribe. In any other field of medicine the evidence presented would imply the opposite conclusion to that presented here. Competing interests: None declared |
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Kelsey D J Jones, Academic Clinical Fellow in Paediatrics Department of Paediatrics, Imperial College (St. Mary's Campus), Wright-Fleming Institute, London W2, David Porter, Huw Williams
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Parker et al’s review of the diagnosis and treatment of alcohol misuse did not address the distinct problems and needs of adolescent drinkers, many of whom will present to health services intoxicated in the Emergency Department (1). Alcohol misuse is very common in this age group and its incidence is rising, at great cost to individuals, families and wider society (2,3). It is significantly associated with risk of suicide, violence, and accidents; the commonest causes of death for young people (4). It is also an important marker of serious social problems, with significantly higher levels of physical and sexual abuse within the family for teenage drinkers, issues that must be explored with all those who present to health services (5). Despite this, Emergency Department physicians are often deficient at screening for alcohol misuse in young people (6), and are poor at recognising it without the use of formalised screening tools (7). This problem is compounded by difficulties in interpreting common verbal alcohol screens in the adolescent age group, which ought to be a major focus of research: AUDIT and its shortened derivatives are acceptable for use in adolescents, though lower cut-off scores than for adults are probably wise, whereas CAGE is less appropriate, as this easy to remember questionnaire detects dependent drinking (8,9). A single question ‘How often do you get drunk?’ identifies young people at risk of traumatic injury through drinking (10), and the Paddington Alcohol Test is effective in identifying ‘binge’ drinkers (11). We wish to stress that testing blood alcohol level at presentation is never a substitute for formalised verbal investigation of drinking habits and risk behaviour, not least because young people are drunk with lower blood alcohol concentrations than adults, and because the pattern of ‘binge’ drinking is intermittent. Emergency Department physicians should also be aware that while it has been reported that young people are more prone to hypoglycaemia when intoxicated than are adults, several series have shown that it is a rare finding (12,13). Other pathologies must be considered in the intoxicated adolescent with hypoglycaemia, including infection or additional toxic and metabolic insults. 1. PARKER, A. J. R., MARSHALL, E. J. & BALL, D.M. (2008): Diagnosis and management of alcohol use disorders. BMJ, 336, 496-501. 2. HIBELL, B., ANDERSON, B., AHLSTROM, S., BALAKIREVA, O., BJARNASON, T., KOKKEVI, A. & MORGAN, M. (2001): The 1999 ESPAD Report; Alcohol and other drug use among students in 30 European countries. Stockholm: Swedish Council for Information on Alcohol and Other Drugs. 3. GILL, J. S. (2002): Reported levels of alcohol consumption and binge drinking within the UK undergraduate student population over the last 25 years. Alcohol Alcohol, 37(2),109-120 4. SWAHN, M. H., BOSSARTE, R. M. & SULLIVENT, E.E.3. (2008): Age of alcohol use initiation, suicidal behavior, and peer and dating violence victimization and perpetration among high-risk, seventh-grade adolescents. Pediatrics, 121, 297-305. 5. SIMANTOV, E., SCHOEN, C. & KLEIN, J.D. (2000): Health- compromising behaviors: why do adolescents smoke or drink?: identifying underlying risk and protective factors. Arch Pediatr Adolesc Med, 154, 1025-33. 6. MORLEY, R. (2001): Investigating the links between alcohol services and the A&E departments. London: Alcohol Concern. 7. WILSON, C. R., SHERRITT, L., GATES, E. & KNIGHT, J.R. (2004): Are clinical impressions of adolescent substance use accurate? Pediatrics, 114, e536-40. 8. FAIRLIE, A. M., SINDELAR, H. A., EATON, C. A. & SPIRITO, A. (2006): Utility of the AUDIT for screening adolescents for problematic alcohol use in the emergency department. Int J Adolesc Med Health, 18, 115 -22. 9. KNIGHT, J. R., SHERRITT, L., HARRIS, S. K., GATES, E. C. & CHANG, G. (2003): Validity of brief alcohol screening tests among adolescents: a comparison of the AUDIT, POSIT, CAGE, and CRAFFT. Alcohol Clin Exp Res, 27, 67-73. 10. O'BRIEN, M. C., MCCOY, T. P., CHAMPION, H., MITRA, A., ROBBINS, A., TEUSCHLSER, H., WOLFSON, M. & DURANT, R.H. (2006): Single question about drunkenness to detect college students at risk for injury. Acad Emerg Med, 13, 629-36. 11. PATTON, R., HILTON, C., CRAWFORD, M. J. & TOUQUET, R. (2004): The Paddington Alcohol Test: a short report. Alcohol Alcohol, 39, 266-8. 12. WEINBERG, L. & WYATT, J.P. (2006): Children presenting to hospital with acute alcohol intoxication. Emerg Med J, 23, 774-6. 13. LAMMINPÄÄ, A., VILSKA, J., KORRI, U. M. & RIIHIMÄKI, V. (1993): Alcohol intoxication in hospitalized young teenagers. Acta Paediatr, 82, 783-8. Competing interests: None declared |
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Neil R Wright, Consultant in Psychiatry of Substance Misuse Nottinghamshire Healthcare NHS Trust, Nottingham, NG3 6AA, Caroline S Cooper
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In their clinical review, ¹Parker, Marshall and Ball advocate psychological interventions for hazardous and harmful drinkers and as a major part of treatment for ‘dependent’ drinkers following a medicated detoxification. What they do not advocate is a psychological-mindedness when assessing the rationale for, and the potential (anti) therapeutic impact of, medicated detoxification. If there existed drinkers who continued their daily consumption only because they experience withdrawal phenomena, then medicated detoxification would be a fine intervention, perfectly matched to needs. However, it would also be redundant because drinking each day only sufficient to suppress withdrawal symptoms quickly results in gradual weaning to sobriety². Severely problematic drinkers not only want to suppress withdrawal; they also have a multitude of motives for becoming intoxicated. Hence, they have strong reasons for relapse during or following medicated detoxification. Our concern is that in the absence of a psychology of medicated detoxification, the possibility that it may not only fail, but also feed a cycle, remains the Elephant in the room. In facilitating abrupt cessation of heavy drinking and affecting a ‘soft landing’, medicated detoxification might foster a sense of protection and an accompanying disregard for the importance of trying to assert any restraint over future drinking. These potential cognitive responses to the experience of medicated detoxification predict accompanying oscillations between drinking (behavioural) extremes. How many doctors have felt there repeat prescription of benzodiazepines to some heavy drinkers have been counter-productive? How often does taking control of habitual drunkenness through prescribing benzodiazepines instil a sense of loss of control in the patient? To what extent does this treatment for ‘dependence’ foster the core symptom of ‘dependence’? Whilst concepts of self-efficacy³ and risk compensation4 provide a credible theoretical basis for this view, currently this remains virgin research territory. Until medicated detoxification is exposed to psychological evaluation, the emperor, Librium, will remain clothed. References 1. Parker AJR, Marshall EJ, Ball DM. Diagnosis and Management of Alcohol use Disorders BMJ 2008; 336: 496-501 2. Porter R. The Drinking Man’s Disease: the ‘pre-history’ of alcoholism in Georgian Britain: Br J Addict 1985; 80: 385-96 3. Banurn A (1997). Self-Efficacy: The Exercise of Control. New York: WH Freeman and Company 4. Adams J (1995). Risk. London: UCL Press Competing interests: None declared |
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Robin Touquet, Consultant Emergency Medicine St Mary's Hospital, Imperial College Healthcare Trust
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In response to Joss Bray's letter - I recommend reading:- 1.Royal College of Physicians, Alcohol - can the NHS afford it? Feb. 2001 4.21-23, pages 33-4 + Appendix 2,3 pages 48,49. 2. Thomson AD et al, Guidelines for Managing Wernicke's Encephalopathy in the AED. Alcohol & Alcoholism 2002;37:513-21. It must be realised that Wernicke's can only be actually diagnosed when a patient is sober i.e. BAC <10mgs/100ml as both alcohol itself and thiamine deficiency produce similar signs. Many such patients leave AED before they are sober, worse, they may be put to the back 'of the queue' being not popular with staff. The BNF has changed its guideline (54 Sept. 2007) recognising this, and also that true IgE anaphylactic (as opposed to dose related anaphylactoid) are very rare indeed with IV B vitamins (the only preparation being Pabrinex). Therefore IV B vitamins should be given at the outset where indicated as above and in BMJ's Clinical Review Box 6, p.499, 1.3.08. Robin Touquet Competing interests: None declared |
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Joss Bray, Substance Misuse Specialist Sunderland
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Many thanks to Robin Toquet for entering the debate on Thiamine supplementation. His comments appear mainly to relate to the AED (Accident and Emergency Department) which has it's own particular issues in management related to timescale and so on - this is not the same as in the community or in a specialist unit where ongoing assessment and support is available over several days. I have read the report of the Royal College of Physicians as suggested - "Alcohol - can the NHS afford it?" of which he was an author. I notice that in paragraph 4.22 it states: "Parenteral high potency vitamin B preparations, including Pabrinex, are associated with a small risk of serious allergic adverse reactions, particularly when given intravenously.140 In 1989 the Committee on Safety of Medicines (CSM) recommended for Parenterovite (withdrawn a few years later) that: a) use be restricted to patients in whom parenteral treatment is essential b) intravenous injections should be administered slowly over 10 mins c) facilities for treating anaphylaxis should be available. These recommendations remain in place in the British National Formulary for intravenous thiamine in the form of Pabrinex. Patients with incipient WE therefore require transfer to an acute medical ward where intravenous B vitamins can be administered and continued in a safe environment. To prevent the neuropsychiatric complications of vitamin B deficiency in patients undergoing alcohol withdrawal in the community, high dose oral thiamine, (200mg/day) together with Vitamin B strong tablets, (30 mg/day) is the treatment of choice." So this report seems to recognise that parenteral Thiamine should only be used when "essential" - presumably when WE (Wernickes Encephalopathy) is suspected - a clinical decision - which as Robin Toquet says, cannot be diagnosed during acute intoxication. Therefore, in the AED, the routine use of parenteral Thiamine may be at least unneccessary, and possibly undesirable - it is certainly not based on clear evidence. IM use is not routinely reccommended in the report - unless WE is suspected - in which case it is a clinical decision to give it rather than to carry on only with oral Thiamine. Community detoxification programmes and Specialist inpatient settings should provide the resources to monitor patients who may develop WE and an appropriate decision can be made then. I hope this takes the debate further and I would welcome further comment. Dr Joss Bray Competing interests: None declared |
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