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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]