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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 Scoring system Questions 0 1 2 3 4 Never Monthly or 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? Never Less than monthly Monthly Weekly Daily or almost daily How often do you have a drink containing alcohol? Your score A total of 5+ indicates increasing or higher risk drinking. An overall total score of 5 or above is AUDIT-C positive. Brief intervention Especially for non-dependent drinkers • 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 Early intervention • Screening, and brief (5-20 minutes) structured advice at point of detection • Significant reduction in alcohol consumption at 612 month follow-up – In a non-treatment seeking population Mean of 34 studies Moyer et al, 2002, Addiction, 97(3): 279-292. © 2002 Wiley-Blackwell. Effect Size Early and brief intervention Especially for non-dependent drinkers Components of Brief Intervention: ‘FLAGS’ – Feedback – Listen – Advice – Goals – Strategies Bien et al, 1993, Addiction, 88 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 Withdrawal Clinical 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 Either: • 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” Pharmacotherapy for relapse prevention and/ or: • 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” Pharmacotherapy for relapse prevention ° = acamprosate treatment • = placebo treatment N = 272 Sass, et al 1996, Arch. Gen. Psychiatry, 53(8): 673-680. Copyright © 2006 American Medical Association. All rights reserved. Naltrexone v Acamprosate COMBINE study (n=1383) • Naltrexone modestly effective. • Acamprosate effect small and not statistically significant • No benefit from combining medications Figure: Anton et al, 2006, JAMA, 295(17): 2010. Copyright © 2006 American Medical Association. All rights reserved. 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 2007 2Chick, 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 E.g. if a heavy drinker can’t or doesn’t want to change drinking • 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 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 Curry Canterbury Hospital & University of Sydney Professor Paul Haber Royal Prince Alfred Hospital & University of Sydney Associate Professor Martin Weltman Nepean Hospital & University of Sydney All images used with permission, where applicable.