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ALCOHOL, DRUGS AND HOSPITALS James Bell Learning Objectives At this completion of this session, you will be able • To take a drug and alcohol history • To provide brief intervention • To use screening and monitoring questionnaires • Outline management of alcohol withdrawal • Respond constructively to IDU admitted to hospital Why do people use drugs? Why do people use drugs? Drug use is normal behaviour Who develops drug problems? Who develops drug problems? 25 Prevalence 20 15 Males (9.0) Females (3.2) 10 5 0 18-24 25-34 45-54 35-44 Age 55-64 65+ Neurobiology of drug use • Drugs of abuse have in common that they act on the “reward pathway” • The reinforcing effect of drugs is reduction in anxiety and creation of a sense of wellbeing • Repeated exposure leads to lasting brain changes, including protracted withdrawal Drug Dependence A maladaptive pattern of substance use leading to impairment or distress Tolerance and Withdrawal Salience Craving Reinstatement after abstinence Persisting use despite harm Communities vulnerable to drug dependence Those without taboos or rewards Especially: - indigenous communities - marginalised communities - deregulated communities Responding to drug problems Distinct area of medicine: • Serious morbidity and mortality • Involves values and choices Simply telling people to stop is of limited value Components of behavioural medicine • Exchange of information • Structure • Support • Relief of symptoms Alcohol and hospitals Alcoholics need not apply Admissions with alcohol problems KCH (2009) CARE_GROUP Elective Emergency Non-Elective Cardiac 44 25 16 Child Health 1 14 1 CSDS 4 Dental 7 26 3 Liver 465 191 109 Medical 8 1716 8 Neurosciences 26 38 49 Renal 15 25 7 Specialist Medicine 3 23 Surgical 67 231 13 Women's Health 3 3 Grand Total 643 2292 206 Total 85 16 4 36 765 1732 113 47 26 311 6 3,141 Health Effects GIT – liver, pancreas, stomach Neurological – WKS, cerebellar ataxia, peripheral neuropathy, siezures Trauma while intoxicated Mental health What is the nurses role? Alcoholics need not apply Thiamine Offer prophylactic oral thiamine to harmful or dependent drinkers: − a) malnourished or at risk of malnourishment − b) decompensated liver disease or − c) in acute withdrawal − d) before and during a planned medically assisted detoxification Offer prophylactic parenteral thiamine to a and b above who attend an emergency department or are admitted to hospital High dose parenteral thiamine for Wernickes encephalopathy 1. Taking an alcohol history Alcohol consumption in men and women and risk of social and health problems Alcohol Intake (units/week) Risk of Problems Men Women 0-21 0-14 Low Men Women 22-50 15-35 Increasing (Hazardous) Men Women >50 >35 High (Harmful) Alcohol content of what other people drink BEVERAGE APPROXIMATE ALCOHOL CONTENT (%) UNITS OF ALCOHOL PER CONVENTIONAL MEASURE (1 unit=8g=10mL) i) Ordinary beer 3 1.5 per can (2 per pint) ii) Strong beer 4.6 – 6.0 3 per can (4 per pint) iii) Extra-strong beer 7.5 – 9.0 4 per can (5 per pint) iv) Cider/Strong cider 4/6 3 / 4 per pint WINE (eg table wine) 10-14 8-10 per bottle (2-3 per glass) FORTIFIED WINES (eg sherry, port) 13-16 13 per bottle(1 per small standard measure) SPIRITS ( eg whisky, gin, brandy, vodka) 38-40 30 per bottle(1 per standard single measure) BEER AND CIDER Optimal Responses 1. All patients Document alcohol (& drug use) history Consider Alcohol Problems (Index of suspicion) - alcohol-related disease - alcohol dependence Alcohol History When did you last drink alcohol? How much did you drink on that day? And the drinking day before that… Check whether last 2 drinking days were typical Calculate units/week Screening Questionnaires - FAST 1. 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? Only answer the following questions if the answer above is Never (0), Monthly (1) or Less than monthly (2). Stop here if the answer is Weekly (3) or Daily (4). 2. How often during the last year have you failed to do what was normally expected from you because of drinking? 3. How often during the last year have you been unable to remember what happened the night before because you had been drinking? 4. Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down? Index of Suspicion • Presents intoxicated / smelling of EtOH • Isolated raised GGT • Alcohol-related disease Optimal Responses 2 2. Patients drinking above recommended limits • Provide advise on safe levels • Personalise health risks • FU monitoring by GP • If being admitted • Monitor for withdrawal Optimal Responses 3 3. In patients requesting help, referral to local services Southwark – Foundation 66 Lambeth - Lorraine Hewitt House 02032281500 Or contact hospital substance misuse nurse Alcohol Withdrawal Features Autonomic overactivity (tachycardia, hypertension, fever, sweating, agitation, coarse tremor) Perceptual disturbances (vivid dreams, illusions, hallucinations) – such as seeing snakes, feeling insects crawling on the skin (“formication”). Disturbances of cognition, apprehension, paranoia, and delirium GIT disturbances Seizures may occur (usually 7-24 hours after last drink) Rarely, proceeds to agitated, tremulous delirium (DTs) Alcohol Withdrawal Scale Patient Name_______ DOB _______ Date Time ___ ___ ___ ___ ___ Perspiration ___ ___ ___ ___ ___ Tremor ___ ___ ___ ___ ___ Anxiety ___ ___ ___ ___ ___ Agitation ___ ___ ___ ___ ___ Temperature ___ ___ ___ ___ ___ Hallucinations ___ ___ ___ ___ ___ Orientation ___ ___ ___ ___ ___ TOTAL ___ ___ ___ ___ ___ Management of Alcohol Withdrawal (Parenteral pabrinex) (supportive nursing care) Prevent rather than manage withdrawal Chlordiazepoxide protocol Management of Alcohol Withdrawal Chlordiazepoxide Score 4-8: GIVE 20mg, REVIEW in 2 hours If AWS score stable, continue 20mg QID day 1, then taper Score is >8: GIVE 40mg and REVIEW in 2 hours If AWS score stable or falling, continue chlordiazepoxide 40mg QID If patient becomes sedated at any point, withhold chlordiazepoxide Responses Patient All presentations to ED, and wards Action Alcohol, smoking, drug use documented Patient drinking >21 units/week, Brief advice on safe drinking, Alcohol related presentation monitor with AWS _____________________________________________ In alcohol withdrawal* Initiate withdrawal protocol Acute risk of withdrawal Alcohol-related disease consult alcohol liaison nurse Requesting help with drinking (Working hours) _____________________________________________ *If patient presents to ED in withdrawal, is too unwell to be safely sent home, and has no other medical reason for admission to KCH, contact AAU re transfer of patient for continuing management. Questions Why do heroin addicts receive methadone? Opioid Substitute Treatment of Addiction 1. Controlled Supply 2. Stabilization (minimize intoxication and withdrawal) 3. Diminish reinforcing effects of street heroin 4. Structure – attendance and monitoring 5. Support Person on methadone (or buprenorphine) admitted 1. Continue medication 2. In addition, usual analgesia, may need titration 3. If head injury / hepatic encephalopathy, may need dose reduction 4. Note drug interactions (anticonvulsants, rifampicin, other CYP inducers) Heroin User Admitted 1. Appropriate to initiate methadone in order to avoid withdrawal 2. Beware low tolerance, initiate 20mg, may repeat in 4 hours 3. Generally 40mg/day is sufficient to block withdrawal 4. Do not admit simply to manage heroin withdrawal GBL GABA b agonist, precursor of GHB • Produces confidence, charm, relaxation (“charisma”), sexual disinhibition • In higher doses produces prompt sleep • Narrow therapeutic index – risk of OD • Usage mainly in gay males Why do People use GBL? 1. Socialising 2. Sex 3. Sleep GBL - Dependence • Uncommon? • Involves dosing every 1-2 hours • Can develop rapidly (eg after a “long weekend” of partying) • Often occurs when drug is used for sleep • Associated with social withdrawal, emotional blunting, compromised social role GBL Withdrawal Onset rapid – 3-4 hours Can occur after awaking from OD May be severe (delirium, agitated psychosis, severe anxiety and insomnia) Several cases required ICU management UK experience – people admitted for elective detox have required ICU transfer (delirium, rhabdomyolysis) GBL Withdrawal and Management • Initiate high dose diazepam (20mg 2nd hourly) early. “Usual” dose 70-90 mg day 1 • Baclofen 10mg tds • Transfer to AAU (more appropriate setting) Questions [email protected]