1.0 Introduction. 3.0 Description and Definitions. 2.0 Context of alcohol use

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1 C AT E G O R Y I I S P E C I A L I T I E S & S E T T I N G S : A LC O H O L A N D T H E E M E R G E N C Y D E PA R T M E N T SUBSTANCE MISUSE FACT SHEETS 1.0 Introduction Acoho misuse poses a major probem in modern society. Physica and psychoogica acoho-reated harm resut in arge numbers of Emergency Department (ED) attendances. Emergency services face increasing pressure as a consequence of acoho misuse. Acoho reated attendances at Emergency Departments may occur as a direct resut of acoho misuse through acute intoxication and/or the onger term effects of chronic acoho misuse. Patients may aso present with conditions associated with acoho ingestion incuding trauma, assauts, road traffic accidents, and domestic vioence. Consequenty, the cost to the NHS of acoho reated harms continues to grow. Emergency Departments have a key roe in identifying individuas who may be at risk of deveoping or have deveoped acoho reated heath issues and to impement interventions, which may utimatey reduce acoho reated harms, to the individua, their famiies and society as a whoe. L E A R N I N G O U T C O M E S Medica students wi be skied in: 1. Identification of the signs/symptoms reated to acoho misuse. 2. Recognising that attendance at an Emergency Department provides an opportunity for brief intervention and heath promotion advice. 3. Providing information on the heath risks associated with chronic acoho misuse. 4. Recognising the signs and symptoms of acoho withdrawa and how to manage these. 2.0 Context of acoho use Acoho currenty costs the NHS an estimated 3.5 biion/year Attendance at Emergency Departments aone accounts for 1 biion/year. In 2012, approximatey 1.2miion peope attended Emergency Departments as a resut of excessive acoho consumption, either acutey or chronicay. This is a rise of 50% since Acoho reated hospita admissions continue to rise in 2013/14, there were an estimated 1,059,210 admissions an increase of 5% over the 2012/13 figure of 1,008,850. (HSCIC 2015). Societa cost of excess acoho use is approximatey 21 biion (Pubic Heath Engand Acoho treatment in Engand ). Up to 40% of patients presenting to the ED during the day and 70% of patients presenting at night, have been drinking prior to their attendance. Amost haf of a assauts are acoho reated (I.A.S (2013), Budd 2003) and 14% of road traffic accidents are reated to iega bood acoho eves. (Department of Transport 2016). Excessive acoho consumption is associated with over 40 medica conditions incuding stroke, cancer, heart disease, hypertension and iver disease and is thus a major preventabe cause of mortaity and morbidity. In the UK, 33.5% of aduts aged 16 years and over have a disorder of acoho use, spanning from individuas who drink harmfuy (incuding binge drinking) through to those who 1 are acoho dependent. Acoho dependence is estimated to affect between 3-6% of aduts in Engand. (NICE 2011) and 18% are beieved to binge drink. Reducing acoho reated harm is thus a major government priority (Department of Heath 2010). 3.0 Description and Definitions Consumed in moderation acoho can faciitate socia interaction and in sma amounts is associated with a ower risk of coronary heart disease and stroke. However when consumed excessivey, acoho promotes risk taking behaviours and may make patients vunerabe to a range of negative ife events incuding assaut, sexua assaut, unprotected sexua intercourse, and road traffic coisions. Chronic exposure to acoho affects a body systems and has a range of negative heath consequences. (Tabe 1) Over time toerance and dependence may occur. Recommendation on acoho intake In January 2016, the government pubished new guideines for acoho consumption (DH, 2016), recommending that men and women shoud drink no more than 14 units of acoho per week and that these units shoud be spread across severa days. A further recommendation is not to save up the 14 units for 1 or 2 days, but to spread them over 3 or more days. Peope who have 1 or 2 heavy drinking sessions each week increase the risk of death from ong term inesses, accidents and injuries. A good way to reduce acoho intake is to have severa acoho free days a week.(dh, 2016). If episodes of heavier drinking occur, a 48 hour acoho free period is recommended. (Patient.co.uk 2012). The Roya Coege of Physicians (2011) recommends that the maximum weeky aowance for men shoud be 21 units and 14 units for women, with 2-3 acoho free days per week. Some argue that the recommended weeky aowance remains too high, as there appears to be an increased risk of deveoping certain cancers, even at ower eves of consumption. Harmfu Drinking: Harmfu drinking is defined as a pattern of acoho consumption causing heath probems directy reated to acoho (NICE 2011).

2 Acoho Dependence: a subjective awareness of compusion to drink on reguar basis, with increasing acoho toerance. Abstinence may resut in withdrawa symptoms. Binge Drinking: >8 units for men, 6 units for women in one day. Cacuating Acoho Units The abiity to accuratey cacuate the number of units a patient is drinking is required. One unit of acoho is 10m by voume (or 8gm by weight) of pure acoho. Acohoic beverages are abeed with percentage acoho by voume (%ABV) The number of UK units of acoho in a drink can be cacuated by mutipying the voume of the drink (in miiitres) by its % ABV, and dividing by 100. E.g. One Imperia pint (568ms) of beer at 4% ABV contains: 1 unit of acoho is about equa to: Haf a pint of reguar strength beer, ager or cider ( 3-4% ABV) A singe (25m) pub measure of spirits (40% ABV) 1.5 units of acoho is about equa to: A sma gass (125m) of standard strength wine ( 12% ABV) A 35m measure of spirits ( 40% ABV) It shoud be noted that many wines and beers that are currenty avaiabe are stronger than the %ABV stated above. Additionay if patients are drinking at home and sef-pouring it can be difficut to ascertain voumes accuratey. 4.0 Heath risks associated with excessive acoho consumption. Drinking above the recommended guideines on a reguar basis (Men 3-4 units/day, women 2-3 units/day reguary) is associated with increased heath risks: Men are twice as ikey to get cancer of the mouth, pharynx or arynx, whie women are 1.7 times more ikey. Women increases their risk of breast cancer by approximatey 20%. Men and women are 1.7 times more ikey to deveop iver cirrhosis. Men are 1.5 times more ikey to deveop high bood pressure and women 1.3 times more ikey. With higher eves of consumption heath risks increase further (NHS 2012). Tabe 1: physica and psychoogica heath hazards associated with acoho abuse (Adapted from: Roya Coege of Physicians, 2001) System Nervous system Liver Gastrointestina system Cardiovascuar system Respiratory system Endocrine system Reproductive system Occupationa/ socia Chidren of probem drinkers Drug interactions Psychoogica Associated issues Acute intoxication, backouts, seizures, brain damage, stroke, head injury, periphera neuropathy, chronic/ acute subdura haemorrhage Fatty iver, acohoic iver disease, iver faiure, cirrhosis, hepatoceuar carcinoma, porta hypertension (associated gastro intestina varices) Oseophagitis, gastritis, peptic ucer disease, diarrhoea and maabsorption, acute/ chronic pancreatic probems, gastrointestina beeding Arrhythmias, diated cardiomyopathy and hypertension Rib fractures and pneumonia Pseudo-Cushing s syndrome and hypogycaemia, gynaecomastia Hypogonadism: associated with oss of ibido, impotence, reduced/absent sperm formation, risk of breast cancer Impaired work performance and decision making, increased risk of accidents, sick days, criminaity, debt Damage to the foetus, detrimenta effect on physica deveopment and behavior, foeta acoho syndrome Increased risk of adverse drug reactions, reduced effectiveness of therapeutic drugs, non-compiance with medications, accidenta overdose of medications Low mood, depression, haucinations, memory probems, anxiety, psychosis, personaity probems Effects on brain receptors: Acoho acute activation of gutamate receptors in the brain resut in feeings of euphoria, oss of judgement and impairment of co-ordination. Chronic activation of gutamate receptors resuts in ce death and cerebear deterioration which may cuminate in Wernicke-Korsakoff syndrome. Acute activation of GABAA brain receptors causes sedation. Chronic GABAA receptor stimuation causes ethargy, impairment of motor skis and reduced co-ordination. 2 Cinica signs of acute acoho intoxication. The cinica signs associated with acute acoho ingestion wi vary depending on the amount of acoho ingested but may incude sme of acoho, surred speech, ataxia, ethargy, vomiting, erratic behavior and emotiona abiity. Severe acoho intoxication may resut in reduced GCS (Gasgow Coma Score) and coapse. Patients with reduced GCS and vomiting may be at risk of airway compromise and aspiration pneumonia. In severe cases, advanced airway protection with intubation and ventiation may be required. In the presence of head injury,

3 patients with reduced GCS shoud have a CT brain preformed to excude intracrania causes of reduced GCS. A patients shoud have bood gucose checked and monitored due to the risk of hypogycaemia. Acutey intoxicated patients are managed supportivey in the majority of cases, with cose observation in the recovery position. Vignette Mr Robertson is a 42 year od buider who presents to the Emergency Department foowing a fa on the way home from the pub. He has worked as a abourer since the age of 16 and rarey misses a working day. He is married with two chidren. He has sustained a head injury and smes of acoho. He is mobie around the department and has a GCS (Gasgow Coma Score) of 15. He has a arge occipita aceration, approximatey 4cm in ength, which wi require sutures. A B C D E G Airway (& Cervica spine) Breathing Circuation Disabiity Exposure Gucose Is the airway cear? Consider added noises: - snoring suggests partia airway obstruction. This may occur due to reduced conscious eve after excess acoho. Aways consider aternative causes of reduced GCS (drugs, hypogycaemia, head injury, sepsis). - gurging may occur due to bood from facia trauma or vomit. Patients with reduced GCS may require airway support. Patients with evidence of a head injury and reduced GCS shoud be assumed to have a cervica spine injury and appropriate immobiisation appied. What are the respiratory rate and oxygen saturations? Is there equa air entry biateray? Are there any added sounds in the ung fieds? Patients who have vomited are at risk of aspiration. Chest trauma may occur foowing coapse/ fas. Look for bruising or deformity. Co-ingestion of depressants may resut in reduced respiratory rate and de-saturation. What is the puse rate and bood pressure? Acoho may be associated with atria fibriation foowing acute or chronic use. Chronic acoho use is associated with hypertension. Consider occut injury in patients who are acutey intoxicated. Fas may resut in chest/abdomina/ pevic injuries or fractures. Patients may not aways report pain. Is the patient aert? (AVPU/Gasgow Coma Score (GCS) Pupi examination: Size, symmetry, reactivity. Does the patient have externa evidence of a head injury? Is the patient moving a 4 imbs equay? Arrange CT brain in patients with head injury who fufi criteria in NICE (2014) guideines for Head Injury Management. Check patient for other injuries Stigmata of iver disease: spider naevi, gynaecomastia,pamar erythema suggest chronic acoho abuse Temperature: due to vasodiatory properties of acoho patients are at risk of hypothermia. Bood gucose checked due to risk of hypogycaemia. Further things to consider: Has the patient had any other Emergency Department attendances reated to acoho misuse? Patients must be safey mobie prior to departure from the department. This may require a period of observation/admission, to sober up. Patients who have a head injury shoud be assessed according to NICE Guideines and a CT brain performed as 3 indicated. On discharge they shoud be given appropriate written advice. Patients who have sustained cuts/acerations/ abrasions shoud have tetanus status documented and receive immunization as appropriate. Athough bood acoho concentrations can be measured in many hospitas, they are rarey utiized in the Emergency Department, as they do not infuence management.

4 Aways be wary of attributing reduced GCS to acoho consumption and consider a possibe causes of reduced GCS. A patients who present to the Emergency Department shoud have an acoho, tobacco and recreationa drug use history recorded and appropriate heath promotion advice given. Patients who report acoho consumption above recommended amounts, or have attended as a consequence of acoho, shoud have a brief intervention prior to discharge. Acoho Withdrawa Individuas, who have become physioogicay dependent on acoho and subsequenty stop, significanty reduce their acoho intake or are unabe to drink due to iness, are at risk of withdrawa symptoms. This may occur within a few hours of the ast drink. Patients who have attended the Emergency Department acutey intoxicated but have been admitted for observation or to sober up, may aso be at risk of withdrawa during their admission. In mid cases, patients may experience nausea or vomiting, tremor, anxiety, and sweating. In more severe cases, patients may experience auditory, visua or tactie haucinations, autonomic instabiity (incuding tachycardia and pyrexia). Severe compications of acoho withdrawa incude seizures, deirium tremens (DT s) or Wernicke s Encephaopathy. Acoho withdrawa and its sequeae are common presentations to the Emergency Department. Prompt recognition of acoho withdrawa and rapidy administered treatment is required to reduce the significant associated morbidity and mortaity. Patient shoud be examined systematicay using an ABC approach. Things to consider incude: Patients may present during or foowing a seizure. Patients may require airway support due to reduced GCS or persistent seizure activity despite anti-seizure medication administration. Patients who are confused, have had seizures or have externa evidence of head injury, shoud be discussed urgenty with a senior Emergency Doctor for consideration of a CT brain to excude intracrania beeds. Consider the possibiity of cervica spine injury in any patient with externa evidence of a head injury. Is there an aternative cause for the patient s symptoms and signs? These might incude sepsis, intracrania pathoogy, toxicoogica, hypogycaemia and psychiatric causes. Manourishment may resut in eectroyte abnormaities incuding hypokaaemia and hypomagnesaemia. These shoud be identified and corrected. Eectroyte abnormaities increase the risk of cardiac arrhythmia. Manutrition is associated with vitamin deficiencies. In the ED, high dose parentera Vitamin B shoud be administered to reduce the risk of Wernicke s Encephaopathy. Anaytica confirmation of deficiency is NOT required prior to administration. Examine for stigmata of chronic iver disease. Abdomina pain is a common probem in chronic acoho users. Consider: pancreatitis, gastritis, peptic ucer disease, perforation of duodena/ gastric ucers, spontaneous bacteria peritonitis, acoho- induced hepatitis. Consider acohoic ketoacidosis when patients are vomiting. Perform bood gas for acid-base disturbance. Scoring Systems for Acoho Withdrawa The most commony utiized system for scoring acoho withdrawa is the Cinica Institute Withdrawa Assessment of Acoho Scae, Revised (C.I.W.A-Ar)( Suivan 1989) Acute Management of Acoho Withdrawa The first ine treatment of acoho withdrawa management is administration of benzodiazepines. The use of a ong acting ora benzodiazepine, such as chordiazepoxide is preferred for the management of withdrawa symptoms. In the Emergency Department, severe withdrawa symptoms may require the administration of a parentera (intravenous) benzodiazepine, such as diazepam or orazepam, due to rapid onset of action. Intravenous management of acoho withdrawa syndrome shoud be discussed with a senior Emergency Department doctor. In patients with significant iver disease, there is an increased risk of toxicity from benzodiazepines, due to changes in metaboism and cearance. A patients must have their puse, bood pressure, puse oximetry, respiratory rate and GCS monitored cosey to identify potentia toxicity from benzodiazepines. Patients shoud be reguary assessed using a vaidated scoring system for acoho withdrawa, such as the C.I.W.A to guide benzodiazepine administration. Patients shoud have baseine bood tests performed incuding Fu Bood Count, Rena Profie, Liver Function Tests, amyase, Coaguation Screen and magnesium eves performed. In patients where sepsis is a possibe differentia diagnosis, chest x-ray and urinaysis shoud be performed. Suspicion of centra infections may require CT brain +/- Lumbar puncture. Suspicion of spontaneous bacteria peritonitis might require ascitic tap for microbioogy, cuture and sensitivity. Administration of high dose parentera B vitamins (Pabrinex) is generay indicated in a patients who attend the Emergency Department with acoho withdrawa symptoms. Acoho abusers and manourished individuas have a reduced abiity to absorb thiamine, in addition to generay having poor dietary intake. Administration of high dose B vitamins, aims to prevent the deveopment of Wernicke s encephaopathy. Seizure and status epiepticus in acoho dependent patients are managed as per Advanced Life Support guideines for seizure management. Deirium Tremens Occur in approximatey 5% of patients with acoho withdrawa, usuay 2-3 days foowing cessation of acoho. Untreated it has a high morbidity and mortaity rate of 15-20%. Characteristic symptoms incude severe tremor, ateration in consciousness, 4

5 acute confusion, autonomic instabiity (tachycardia and fever) and severe haucinations. Eary detection and management wi usuay prevent onset (Wyatt 2012). Wernicke s Encephaopathy The cassica triad of symptoms: acute confusion, ataxia and ophthamopegia occur in ony 10% of patients. Due to acute deficiency of thiamine, treatment invoves rapid restoration with high dose intravenous thiamine administration. (Pabrinex) (Wyatt 2012). This is important to avert Korsakoff s Syndrome. Barriers to detecting acoho issues in the Emergency Department. Patients may not aways offer reiabe information regarding their acoho consumption, smoking history or use of recreationa substances. It is a key aspect of the socia history that a patients are asked about acoho, smoking and recreationa drug use, incuding prescription drugs. Factors that may inhibit discosure incude socia stigma, potentia impact on empoyment or fear of invovement of poice or socia services (e.g. foowing road traffic accidents, young chidren at home). Remember patients may not aways present at the time of injury consider acoho use in deayed injury presentations. Potentia questions When asking questions about acoho, ask questions about amount, type, frequency and circumstances. Beow are some exampes of questions you coud ask to eicit the information. Exampes of questions Do you drink acoho? What do you usuay drink? How many days a week do you have a drink? How much do you usuay drink? Are there any days when you don t have a drink? Show me how big a gass you might use What time do you usuay have your first drink of the day? How do you usuay get your drink? Do you fee that your current attendance at ED is reated to acoho? Have you previousy been to ED for an attendance that was aso reated to acoho? Have you ever considered changing your drinking in anyway? Do you have any concerns about the amount of acoho you drink? Woud you ike to reduce the amount of acoho you drink? Have you ever received any hep in attempt to reduce your acoho intake? Reason for asking Ask everyone. Even if you think they may not drink, it is important to ask everyone. For exampe, in some cutures drinking acoho is not permitted. However, this does not mean that peope from that cutura background do not drink and may not have probems. May give an indication of eve of probems, as some acohoic drinks are known to have a high %acoho voume, such as specia brew and spirits. Some drinks are more costy than others and this may aso be an indication of the probems someone may be facing if they are not working and may have reduced access to disposabe income to fund their drinking. It is aso hepfu to ask about a drinks and suggest types, so that if there are memory issues (particuary for oder peope, or those affected by head injury), you don t get a no answer to a coective name and it might be an aide memoir (e.g. red wine, white wine, sherry, spirits) to name a few. To estabish reguarity of drinking. To be abe to assess the units the individuas is drinking. Daiy drinking may be an indication of dependence. Estabish whether drinking is inked to access to money (e.g. pay day, days they receive benefits). You are trying to assess severity of drinking and whether the individua is drinking at hazardous eves. To assess whether there is a dependence and whether the individuas is abe to contro drinking. Peope do find it difficut to know how much they drink, and so might use terms such as sma gass, if they show you (compared to another drinking vesice) it gives the assessor an indication of size, as they may be drinking more than they describe. Exampe: first thing in the morning, unchtime or evening. This may give an indication of the ikeihood of dependence. Is it part of routine shopping or does someone buy acoho for them? This aso heps to estabish insight into the presenting probems and the ink to acoho. To estabish whether there is a history of acoho reated attendance. This may indicate the need for an onward referras such as refer to acoho iaison services in the ED (if they are avaiabe), referra to psychiatric iaison, other services and to set up and appointment with other services ocay. Assess insight, wiingness to accept there may be a probem and wiingness to accept some hep. 5

6 For oder peope, you may ask other questions, specificay reated to oder peope Have you ever needed to ask someone passing by to go and buy you something? Assessing severity of probem and vunerabiity. How much do you think you spend on your drinking? How does drinking affect you (seep, waking, movements, concentration) What woud happen and how woud you fee, if you didn t have a drink or drank ess? Get a sense of whether drinking has an impact on other needs, such as buying food and other provisions. Obtain the person s own view of any effects and whether this is a probem or stops them doing their usua activities during the day. 5.0 Screening Toos There are a range of screening toos that may be used to assess acoho intake. Choice of screening too may be affected by Departmenta and/or persona cinician preference. The most frequenty used toos in the ED are isted beow. Fast Acoho Screening Test ( FAST) AUDIT ( Acoho Use Disorders Identification Test) is a screening instrument of good sensitivity and specificity for detecting hazardous and harmfu drinking among peope not seeking treatment for acoho probems Paddington Acoho Test (PAT) Severity of Acoho Dependence Questionnaire (SADQ ) 6.0 Brief Interventions in the Emergency Department It is widey recognized from studies in the UK and internationay that brief interventions in the Emergency Department are effective in reducing acoho reated harms. The purpose of the brief intervention is that it heps the patient think about their own acoho intake and the reationship of this to their heath and we-being. A brief intervention is a practice that aims to identify a rea or potentia acoho probem for an individua, and motivate that individua to do something about it. (WHO 2014) The brief intervention may take as itte as 5 minutes. A brief intervention shoud incude 1. An understanding of how much the patient is drinking (quantity and frequency). 2. Any negative effects the patient may be experiencing or potentia harm(s) that may resut occur as a consequence of their acoho consumption. 3. Exporing the benefits of reducing or stopping acoho consumption. 4. Expore the potentia barriers to change. 5. What is the patient s persona target- Reduce acoho or stop drinking? 6. What pans might a patient put in pace to reduce/ stop drinking? What hep might they require to achieve this aim? Potentia benefits of reducing acoho consumption may incude improved mood, improved persona reationships and financia benefits. Physica benefits might incude improved seep, increased energy, weight oss, improved memory, reduced risk of injury and no hangovers. Long term heath benefits incude reducing risk of hypertension, cancer, iver disease. 7.0 References and usefu resources Acoho Concern (2014) The Acoho Harm Map Budd T. (2003) Acoho reated assaut: findings from the British Crime Survey. Department of Heath (2106) UK Chief Medica Officers Acoho Guideines Review Summary of the proposed new guideines fie/489795/summary.pdf Department of Heath ( 2016) Updated acoho consumption guideines give new advice on imits for men and pregnant women Department of Heath (2010) White Paper: Heathy ives, heathy peope: our strategy for pubic heath in Engand. Avaiabe at: fie/136384/heathy_ives_heathy_peope.pdf Department of Heath and Nationa Treatment Agency for Substance Misuse (2006) Modes of Care for acoho misusers update Department of Transport (2016). Reported road casuaties in Great Britain: Estimates for accidents invoving iega acoho eves: 2014 (second provisiona) fie/497662/accidents-invoving-iega-acoho-eves-2014.pdf EMCDDA (2106) Emergency department-based brief interventions for individuas with substance-reated probems: a review of effectiveness ment-based-brief-interventions Ghodse H.(2010) Ghodse s Drug and Addictive Behaviour A guide to treatment 4th edn. Cambridge & New York: Cambridge University Press. Heath and Socia Care Information Centre (2015) Statistics on Acoho- Engand rep.pdf Huntey JS, Bain C, Hood S, Touquet R. (2001) Improving Detection of acoho misuse in the patients presenting to an accident and emergency department. Emergency Medicine Journa 2001;18: Institute of Acoho Studies (2013) Acoho and oder peope: Heath impacts: Hospita admissions. Institute of Acoho Studies (2013). UK Acoho- reated crime statistics. 6

7 Koher,S. & Hofmann, A. (2015) Can Motivationa Interviewing in Emergency Care Reduce Acoho Consumption in Young Peope? A Systematic Review and Meta-anaysis. Acoho & Acohoism. 50: Mann C.J. (2016) The burden of acoho Emerg Med J;33: doi: /emermed Mayo-Smith MF.(1997) Pharmacoogica treatment of acoho withdrawa. A meta-anaysis and evidence based practice guideine. American Society of Addiction Medicine Working Group on Pharmacoogica Management of Acoho Withdrawa. JAMA 1;278(2): NHS (2012): Your Drinking and You: The Facts on acoho and how to cut down. Drinking_And_You.pdf NICE (2011) Acoho Dependence and harmfu acoho use quaity standard. NICE (2010) Cinica Guideine CG100Acoho-use disorders: Diagnosis and Cinica Management of acoho-reated physica compications. Avaiabe at: NICE (2011) Cinica Guideine CG115 Acoho-use disorders: Diagnosis, assessment and management of harmfu drinking and acoho dependence. Avaiabe at: NICE (2014) CG 176 Head Injury: Triage, assessment, investigation and eary management of head injury in chidren, young peope and aduts. Office of Nationa Statistics (2013) Acoho Statistics. Parkinson K et a (2016), Prevaence of acoho reated attendance at an inner city emergency department and its impact: a dua prospective and retrospective cohort study. Emerg Med J;33: doi: /emermed Patient.co.uk (2015) Acoho and sensibe drinking Pubic Heath Engand Acoho Learning Centre (2012).Emergency medicine topic- screening toos Medicine/ Pubic Heath Engand (2014) Acoho treatment in Engand commentary.pdf Roya Coege of Emergency Medicine (2015) Acoho Reated Harm Position Statement Cinica%20Guideines/Coege%20Guideines/ Roya Coege of Emergency Medicine (2015) A tookit for improving care Foor/Cinica%20Guideines/ Coege%20Guideines/ Roya Coege of Physicians (2001) Acoho- Can the NHS afford it? Recommendations for a coherent acoho strategy for hospitas. Roya Coege of Physicians (2011). The evidence base for acoho guideines. Written evidence submitted by the Roya Coege of Physicians (AG 22) to the House of Commons Science and Technoogy Committee, UK Pariament Session writev/1536/ag22.htm Siva N ( 2015) Tacking the UK's acoho probems. The Lancet Vo 386, p Suivan JT, Sykora K, Schneiderman J, Naranjo CA, Seers EM. (1989)Assessment for acoho withdrawa: the revised cinica institute withdrawa assessments for acoho scae (CIWA-Ar) Br J Addict 1989;84(11): Turner RC, Lichstein PR, Peden JG, Busher JT, Waivers LE.(1989) Acoho withdrawa syndromes: a review of pathophysioogy, cinica presentation and treatment. J Gen Int Med;4 (5): Word Heath Organisation (2014) Screening and brief Intervention for acoho probems in primary heath care. Wyatt J, Iingworth R, Graham C, Hogg K (2012). Oxford Handbook of Accident and Emergency Medicine. 4th ed. Oxford University Press March