alcohol (part 2) management © 2009 university of sydney
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Alcohol (Part 2)Management
© 2009 University of Sydney
Learning outcomes
To be able to provide:• Management of hazardous and harmful
drinking:– Screening– Brief intervention
• Management of dependence– Motivational interviewing– Withdrawal management– Relapse prevention– Monitoring– Harm reduction
Case study
• Chloe is a 38 year old new patient who presents requesting a script for an anti-hypertensive.
• When you take an alcohol history you discover she drinks 3 cans of beer most nights of the week with up to six glasses of wine on a Saturday.
Questions• What should she do about her drinking? What
goals should she aim for?• How will you help convince her to change her
drinking?
Screening for alcohol problems
• Screen every patient– Validated questionnaires e.g. AUDIT,
CAGE
• AUDIT-C (AUDIT items 1-3)– Asks patient how much and how often they
drink:• Quantity• Frequency• Episodic heavy drinking, eg Saturday nights
AUDIT-C
Questions
Scoring systemYour score0 1 2 3 4
How often do you have a drink containing alcohol?
NeverMonthlyor less
2 - 4 times per month
2 - 3 times per
week
4+ times per
week
How many units of alcohol do you drink on a typical day when you are drinking?
1 -2 3 - 4 5 - 6 7 - 8 10+
How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?
NeverLess than monthly
Monthly WeeklyDaily or almost daily
A total of 5+ indicates increasing or higher risk drinking.An overall total score of 5 or above is AUDIT-C positive.
Brief intervention
• Proactive detection of drinking problems• Advice or counselling at the point of
detection• Used for non-dependent (hazardous and
harmful) drinkers• Also to help engage/motivate dependent
drinkers
Especially for non-dependent drinkers
Early intervention
• Screening, and brief (5-20 minutes) structured advice at point of detection
• Significant reduction in alcohol consumption at 6-12 month follow-up– In a non-treatment seeking
population
Moyer et al, 2002, Addiction, 97(3): 279-292. © 2002 Wiley-Blackwell.
Mean of 34 studies
Effect Size
Early and brief intervention
Components of Brief Intervention: ‘FLAGS’– Feedback– Listen– Advice– Goals – Strategies
Bien et al, 1993, Addiction, 88
Especially for non-dependent drinkers
Brief intervention
• Feedback: – evidence of harm experienced from drinking– Or risks faced if drinking continues at this
level
• Listen: – to whether the patient is prepared to consider
changing their drinking– or whether perhaps they have tried to change
it many times before
Brief intervention• Feedback• Listen• Advice: clear advice that they
should cut down
• Goals : what should they be aiming for?
• Strategies: practical ways of changing drinking
Strategies for reducing drinking
• Planning an alternative activity • Limiting time with drinking friends• Switching from schooners to middies• Switching to light beer• Not drinking alcohol for thirst• Eating when drinking• “Excuses” for peers: “getting fit”, “my
doctor told me to cut down”
After brief intervention
• Can provide with self-help brochure
• Consider a drinking diary
• “Feel free to come back to discuss this again/if you need a bit of help”
Withdrawal management
Alcohol withdrawal
• Can deter a drinker from attempting to stop
• Ranges from very mild overnight withdrawal to life-threatening
• Setting of management will be determined by patient preference, safety issues and history of past withdrawals
Timeframe for withdrawal
• Mild withdrawal: even after overnight abstinence e.g. anxiety, mild agitation
• Seizures: peak risk 6-24 hours
• Typical withdrawal: peak at 48 hours
• Withdrawals finish within a week
Timeframe for withdrawal
NSW Drug and Alcohol WithdrawalClinical Practice Guidelines, MHDAO, NSW Health, 2007
Withdrawal rating scale
• E.g. signs of withdrawal scored 0-4: – Perspiration– Tremor– Anxiety– Agitation– Hallucinations– Axillary temperature– Orientation
Example of Alcohol Withdrawal Chart
Withdrawal management
• If withdrawal syndrome likely
– select setting : home, detox unit, hospital
– Monitor with an alcohol withdrawal scale:
• daily as outpatient via GP, or D&A unit
• 4 hourly or more often as inpatient
• Remember the scale is only useful in the absence of other pathology
– Diazepam titrated against withdrawal scale
If AWS reaches threshold (e.g. 5)
• Diazepam titrated against withdrawal scale:– up to 20 mg per dose until returns below threshold
typically up to 20mg qid on day 1 for an inpatient;10mg qid for outpatient (plus 2 x 20mg prn)
– usually oral– Daily dispensing via GP/D&A unit for outpatients
• Check diagnosis is correct – DDx hypoxia, infection
• Remember risks of diazepam (e.g. airways disease; elderly)
Delirium tremens (DTs)
• Risk factors for a severe withdrawal– Duration and severity of dependence– Past severe alcohol withdrawal
syndrome– Medical and surgical events– Anaesthesia– Age
Delirium tremens (DTs)
• Preventable if withdrawal starts in hospital• Significant (15%) mortality if untreated:
– Dehydration, arrhythmias, medical co-morbidity, suicide
• Management– Diazepam
• Generally IV in small doses (e.g. 2mg at 2-5 minute intervals) to prevent respiratory depression
– Haloperidol if hallucinations– Fluid balance– Thiamine IV 100mg tds– Safe environment
Relapse prevention
Relapse prevention
• Medical role – Pharmacotherapy– Maintenance of therapeutic relationship– Monitoring, feedback, support– Assessment of complications
• Mutual support groups, e.g. AA• Counsellor• Residential program ‘rehabilitation’
Pharmacotherapy for relapse prevention
• Naltrexone 50mg mane– Nausea common, start with half dose– Avoid in liver failure and severe
depression– Reduces reinforcement of drinking– Reduces severity of relapses– Warn re opioid blocking effects– Subsidised by PBS Authority: “part of a
comprehensive treatment program”
Either:
Pharmacotherapy for relapse prevention
• Acamprosate ii tds (reduced if < 60kg)
– May assist in reducing craving– Up to 12 months treatment– Minimal side effects (diarrhoea, pruritus,
rash occasionally)– Start after withdrawal complete– Avoid in renal failure– Subsidised by PBS Authority: “part of a
comprehensive treatment program”
and/ or:
Pharmacotherapy for relapse prevention
Sass, et al 1996, Arch. Gen. Psychiatry, 53(8): 673-680. Copyright © 2006 American Medical Association. All rights reserved.
° = acamprosate treatment• = placebo treatmentN = 272
Naltrexone v Acamprosate
• Naltrexone modestly effective.
• Acamprosate effect small and not statistically significant
• No benefit from combining medicationsFigure: Anton et al, 2006, JAMA, 295(17): 2010.
Copyright © 2006 American Medical Association. All rights reserved.
COMBINE study (n=1383)
Disulfiram “Antabuse”• Most effective of available medications if
patient is willing and compliant1
• Works best if dosing is supervised2
• Blocks ALDH activity• Aversive reaction after even a tiny amount
of alcohol: – flushing, palpitations, hypotension,
vomiting, headache• Contra-indications: cirrhosis, heart disease
1Laaksonen, Alc & Alc 20072Chick, Br J Psych 1992
Other medications
• Limited evidence
• Not registered for alcohol treatment
• Baclofen
• Ondansatron
Role of antidepressants
• Many cases of depression resolve with abstinence
• SSRIs: not for drinking per se– If significant depression, can select
an SSRI with less side effect of agitation, e.g. citalopram or sertraline
Harm reduction
• Thiamine: can reduce risk of neurological cx• Duty of care issues
– Driving– Occupation (e.g. train driver, doctor…)– Child protection
• Physical safety issues while intoxicated– Transport home– Risk of violence including sexual assault
E.g. if a heavy drinker can’t or doesn’t want to change drinking
Thiamine
• 100mg tds daily– IM if vomiting, gastritis, very heavy
consumption (unless bleeding disorder)– IV if suspected Wernickes
• (e.g. lateral gaze palsy/nystagmus, delirium, ataxia)
• tds in more severe cases for a week
Summary
• Outcome improves with treatment• Early pro-active detection and
intervention best• Care by D&A specialists not essential
for many drinkers• Withdrawal management possible at
home for many milder cases• New pharmacotherapies improve
duration of remission
Case study• Jane is a 49 year old woman who drinks a small
flagon (500mls) of wine every day. When she tries to stop, she feels very tense and finds she needs a drink to settle herself. On the one time she was admitted for surgery for a week, she required nocte Valium for sleep.
Questions:– Is Jane likely to be dependent?– Is she likely to experience an alcohol
withdrawal syndrome and if so, of what severity?
– Would she be suitable for home detoxification?– What would be the key elements in
management?
Case study - answers
• Jane is likely to be dependent. – withdrawal agitation relieved by drinking– tried to cut down without success (loss of
control)– 5 drinks per day is enough to cause
dependence• Past withdrawal when hospitalised was
very mild, requiring only nocte sedation, hence home detox likely to be possible
• Thiamine; diazepam regime; monitoring; acamprosate; counselling (motivational; CBT; supportive)
Contributors
Associate Professor Kate Conigrave Royal Prince Alfred Hospital & University of Sydney
Dr Ken CurryCanterbury Hospital & University of Sydney
Professor Paul HaberRoyal Prince Alfred Hospital & University of Sydney
Associate Professor Martin Weltman Nepean Hospital & University of Sydney
All images used with permission, where applicable.