Download Presentation on alcohol use disorders for crisis

Management of
Alcohol Use Disorders
Education Rounds
for ED and Hospital Counsellors, Crisis
Workers and Withdrawal Management
Staff
About META:PHI
Mentoring, Education, and Clinical Tools for Addiction:
Primary Care–Hospital Integration
•
Goals:
– Promote evidence-based addiction medicine treatment
– Implement care pathways between the ED, hospital, WMS, primary care, and
rapid access addiction medicine clinics
•
Seven sites in Ontario are currently involved, with plans to expand the spread of
the project in the future
•
Funding and support provided by the Adopting Research to Improve Care (ARTIC)
program (Council of Academic Hospitals of Ontario & Health Quality Ontario)
https://www.porticonetwork.ca/web/meta-phi
META:PHI 2015
Baseline Survey
The baseline survey is anonymous and entirely optional. You may skip any question
that you do not wish to answer. We will not ask you for any personal information
Please tear off and keep the front page with contact information, should you have
any questions about the survey or the META:PHI project.
Please return the completed or incomplete survey face down to the facilitator when
you leave the presentation.
META:PHI 2015
ROLE OF THE COUNSELLOR IN
MANAGING AUDS
META:PHI 2015
Role of the Counsellor in Patients
with an AUD
• In managing alcohol use disorders in the ED,
hospital, or WMS, counsellors play a key role:
– Counsellors spend more time with patients than
physicians
– Patients are more likely to confide in counsellors
than in medical staff
– Counsellors are more likely to provide discharge
advice
– Counsellors can send patients to the RAAM clinic
without a formal MD referral
META:PHI 2015
Beyond Clinical Knowledge
• Counsellors play a significant role in a patient’s early recovery
– Counsellor attitude toward a patient with AUD during their first
treatment encounter can influence their future participation in
treatment
• Showing compassion is essential as often patients seek help
with their substance use after it has gotten them into some
sort of crisis (e.g. partner threatening to leave, children
taken by CAS, DUI, job loss etc.)
• These individuals may be at increased risk for self harm
– A counsellor’s compassion, knowledge and brief counselling
offers patient immediate support and the hope that things will
improve if they continue working on their recovery
META:PHI 2015
Counsellor Goals for
AUD Patients in the ED, hospital, WMS
1. Explain to client what an Alcohol Use Disorder
diagnosis means
2. Provide advice on avoiding alcohol-related harms.
3. Address patient concerns.
4. Provide referral to rapid access addiction medicine
clinic for long term medication-assisted treatment
META:PHI 2015
COUNSELLING YOUR CLIENT ON
THEIR AUD DIAGNOSIS
META:PHI 2015
The Addicted Brain
• Humans have a reward centre in the brain and when an
essential activity for survival is performed (e.g. eating),
dopamine is released
– Dopamine makes us feel good, so we are motivated to repeat
the activity
• Drinking and using drugs also cause a release of
dopamine, more powerful even than with survival
activities
• This is what reinforces people’s substance use, even
when rationally they know it is harmful to them
META:PHI 2015
What is an AUD?
• People with AUDs often have the following four traits:
(1) They cannot control their drinking
(2) They continue to drink despite knowing it is harmful
(3) They spend a lot of time drinking
(4) They have powerful urges or cravings to drink
• AUDs have nothing to do with character, will power, or morals
– Many good and strong people have an alcohol or drug problem
• People with AUDs find that once they start drinking, it is no longer about
choice
META:PHI 2015
Concurrent Disorders
• People with substance use disorders often suffer from other
mental health issues
– These may have contributed to their initial and ongoing
misuse of drugs or alcohol
• Common concurrent disorders include:
– PTSD
– Anxiety
– Depression
• These issues must be addressed through counselling, in
addition to working on issue of substance misuse
META:PHI 2015
AVOIDING ALCOHOL-RELATED
HARMS
META:PHI 2015
Standard Drink Size
Image from Canadian Centre on Substance Abuse
META:PHI 2015
Low-Risk Drinking
• Canada’s low-risk drinking guidelines suggest that:
– Women not exceed 10 drinks a week
• no more than 2 drinks a day most days
– Men not exceed 15 drinks a week
• no more than 3 drinks a day most days
• Both men and women should plan non-drinking days every week to avoid
developing a habit
• Special occasions:
– It is expected that people may drink more on special occasions, but to
minimize risk:
• Women should not exceed 3 drinks on any single occasion
• Men should not exceed 4 drinks on any single occasion
META:PHI 2015
Harm Reduction Advice
• If client drinks in excess of the low-risk guidelines,
you can provide the following advice:
– Consume no more than one drink per hour (or two
drinks every three hours)
– Sip rather than gulp
– Switch to non-favourite drink
– Avoid unmeasured drinks
– Alternate alcoholic drinks with non-alcoholic drinks
– Eat before and while drinking
– Set limits for yourself and stick to them
META:PHI 2015
Alcohol and Trauma
• Risk of trauma dramatically increases with
each drink
• Refer patients to rapid access addiction clinic
even if you think they are just young and
reckless rather than addicted
– Young, weekend heavy binge drinkers are at high risk
of trauma and need treatment even if not daily
drinkers, don’t have withdrawal etc.
META:PHI 2015
Ways to Avoid Trauma if Drinking
• Do not drive a car or boat after drinking
• Do not get in a car or boat with people who
have been drinking
• Do not engage in arguments with intoxicated
people
• Leave a party when strangers arrive, or if it
gets chaotic
• Have a non-drinking friend accompany you
and take you home
META:PHI 2015
Abstinence
• If the patient has a serious AUD (e.g. recurrent
visits to ED for intoxication/ withdrawal), harm
reduction advice is unlikely to work
– Patient needs to remain abstinent
– This goal can be reached through the use of
counselling and appropriate medication
– Counsellors play an important role in emphasizing
that medication works, and is safe
META:PHI 2015
Coping with Cravings –
Advice for Patients in Early Recovery (1)
• Keep busy: Scheduling and keeping a routine can
be a helpful way to avoid using
– Attend self-help groups like NA or SOS, which provide
structure, social support and accountability through
sponsors
– Exercise, take daily walks
– Keep Regular sleeping and eating routines
– Spend as much time as possible with supportive
family and friends who do not use drugs
– Keep appointments with addiction counsellors and
doctors
META:PHI 2015
Coping with Cravings –
Advice for Patients in Early Recovery (2)
• Keep focused: Staying sober requires paying close attention
to how you're feeling, and keeping sobriety as the main
priority
– Take medication prescribed to you by your doctor
– Avoid HALT states: Hungry, Angry, Lonely, Tired
– When feeling the urge to use opioids, pause and call a support
first
– Don't focus on other issues - they can be dealt with later as long
as you remain sober
– Know your triggers and do your best to avoid them (e.g. certain
people or places, or emotions like stress)
– Don't give up - sub-acute withdrawal can last for several weeks
or months, and the anxiety, insomnia, fatigue, and cravings that
you may be experiencing are all temporary
META:PHI 2015
Patient Concern:
Coping with Anxiety and Low Mood
“I feel too anxious and depressed when I'm not drinking.”
• Mood disorders and AUDs often go together.
– If you have problems with your mood as well as with drinking, it is
important that you seek treatment for both issues.
– Treating one often helps with the other:
• if you stop or reduce your drinking, your mood will almost
certainly improve, and if you receive treatment for anxiety or
depression, you are also less likely to drink
META:PHI 2015
Coping with Anxiety and Low Mood (2)
• Patients can employ different strategies to get through cravings brought
on by moods:
– Focus on mindful breathing.
– Remind yourself that cravings only last ~20 minutes. “This will pass, it's only temporary.”
"I've gotten through this before, so I know I can do it now."
– Drink a large glass of water or juice and pause.
– Call a friend or sponsor and visit them if possible.
– Ground yourself in the moment. Look around at what you see, hear, smell, sense.
– Engage in a hobby. What have you enjoyed in the past? What have you always wanted to
try?
– Write down your thoughts and feelings. This helps to get them out of your head.
– Pamper yourself! Do something you really enjoy or do something relaxing.
– Find an affirmation that you can repeat to yourself when you need encouragement
(even if you don't believe it at first!).
– Visualize a drink-free positive future, seeing yourself doing the things you want to be
doing.
– If you have a setback, don't beat yourself up.
• Be aware of what triggered it so that you can avoid being triggered again.
– Just take it one step at a time. Don't plan too far ahead or focus on worries that are not
related to your recovery.
META:PHI 2015
TREATMENT OPTIONS FOR YOUR
CLIENT WITH AN AUD
META:PHI 2015
Patient Concern: Attending Treatment
“Do I really need treatment? Shouldn't I be able to stop
using on my own?”
• Successful recovery from an AUD requires treatment
• Like other illnesses such as diabetes and depression, AUD is caused
by biological, psychological, and social factors, and just like these
other illnesses, it is very hard for patients to manage on their own
– However, effective treatment is available
• Chances of recovery are greatly improved if the patient has:
– had long periods of sobriety in the past
– social supports, such as family and friends
– only one substance of misuse
META:PHI 2015
Treatment Programs and Support
• Counsellors can advise patients of different treatment and
support options available:
– Medication-Assisted Inpatient Programs: inpatient programs that last
up to six months, and incorporate anti-craving medications into
recovery plan
• May be publicly or privately funded
– Abstinence Based Inpatient Programs: inpatient programs that last up
to six months, and do not permit anti-craving medications to be taken
• May be publicly or privately funded
– Outpatient Programs: day programs usually lasting a few weeks,
where patient returns home at night
• May be run through community organizations, withdrawal
management centres, hospitals, or as after-care at organizations
that offer inpatient programs
• May be publicly or privately funded
META:PHI 2015
Other Supports
– Self-help groups can provide valuable emotional
support and information about programs and
services.
• Examples: Alcoholics Anonymous (AAA)
Secular Organizations for Sobriety (SOS)
– Family and friends can offer patients key social
supports which can reduce feelings of loneliness,
and provide activities away from using alcohol
META:PHI 2015
Primary Care
• Family doctors can play a central role in patient recovery
– They can prescribe naltrexone, acamprosate, etc.
– They are able to treat withdrawal, monitor and intervene with mental
and physical health during recovery, and provide ongoing support
during and after treatment
– They can also refer the patient back to treatment if they relapse
• Counsellors can assist the patient in finding a family doctor:
– Health Care Connect (1-800-445-1822) will connect patient to family
doctors and nurse practitioners accepting new patients:
• http://www.health.gov.on.ca/en/ms/healthcareconnect/public/
– Community Health Centres (CHCs) sometimes have openings for
patients within their region
– Locate local CHCs:
• http://www.health.gov.on.ca/english/public/contact/chc/chcloc mn.html
META:PHI 2015
Anti-Craving Medications
• The ED physician or RAAM physician may start the
patient on a medication that helps reduce their alcohol
cravings and binges
• Counsellors play an important role in emphasizing that
these medications are safe and effective
• Common anti-craving medications to be aware of are:
–
–
–
–
–
–
naltrexone
acamprosate
topiramate
gabapentin
baclofen
disulfiram
META:PHI 2015
Medication
What it Does
Is it
Addictive?
Does it cause
nausea if you
drink?
Naltrexone
*Frontline treatment
Reduces alcohol cravings
Reduces rewarding effects of
alcohol
No
No
Acamprosate
*Frontline treatment
Reduces alcohol cravings
No
No
Topiramate
Reduces alcohol cravings
Reduces rewarding effects of
alcohol
No
No
Gabapentin
Reduces alcohol cravings
Improves mood
Improves sleep
No
No
Baclofen
Reduces alcohol cravings
Reduces rewarding effects of
alcohol
No
No
Disulfiram
Makes you sick if you drink
Most effective if dispensed
daily by spouse or friend
No
Yes
META:PHI 2015
Patient Concern: Medication Safety
“Is anti-craving medication safe?”
• All medications prescribed to help with alcohol addiction are safer for your
liver than alcohol is
• You will not need to take these medications for the rest of your life
– Most are taken for the first six months of treatment, as that is often
how long it takes to establish an abstinent lifestyle
• These medications are non-addictive and can be stopped if you find them
ineffective or if they give you side effects
• You and your doctor will go over each medication to determine the
appropriate one for you
META:PHI 2015
WRAP UP – KEY TAKEAWAYS
META:PHI 2015
Key Messages for Patients
• “You have been diagnosed with an AUD”
– This means that you have been unable to stop drinking
alcohol, even though it has become harmful to you
• “Treatment exists and is incredibly effective”
– Explain options for medication-assisted treatment
– Explain options for psychosocial treatment
• “There are things you can do to help cope with
cravings”
• “Once you start treatment, other aspects of your life
will improve tremendously”
– E.g. mood, pain, relationships, daily functioning, finances
META:PHI 2015
Discharge
• Depending on where you see the patient, there are
different referral options
– RAAM Referral
• If you are in the ED, hand patient RAAM referral card
• Non-ED counsellors can also refer the patient, by simply letting them
know clinic hours and location
• RAAM is located close to hospital and patient can be seen in 1-6 days
• Patients do not need to be in withdrawal to be referred
– WMS Referral if warranted
• If patient is in crisis
• If patient needs safe place to stay until RAAM appt
• If patient is keen to start treatment right away
– Medication-Assisted inpatient treatment programs
– Medication-Assisted outpatient treatment programs
META:PHI 2015
Case Scenario - Gary
• Gary is a 46-year-old street-involved man with
a short but severe history of alcohol use. Gary
frequently presents to the ED, usually
intoxicated, occasionally in withdrawal. Gary
arrived at the ED last night severely
intoxicated and was kept overnight. His
withdrawal has resolved and he is ready for
discharge.
META:PHI 2015
Question
• What discharge advice and information would
you provide to Gary?
META:PHI 2015
Management Plan for Gary
• Recommend immediate treatment at WMS (if there is space) and through
support programs like AA
• Advise patient to seek longer term treatment, possibly in a residential
setting
– Let him know that WMS staff can assist in facilitating this
• Refer patient to the RAAM clinic which offers anti-craving medication
• Advise patient to connect with his family doctor if he has one (RAAM
clinic can help him connect with one if he is unattached)
• Provide Gary with a message of hope that treatment does work, and that
he will feel much better once he stops drinking
• Work with him to establish plan to keep busy, now that drinking will not
be in his life
META:PHI 2015