Download Pharmacotherapy for relapse prevention

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.