Transcript Alcohol related problems

2007
ALCOHOL RELATED PROBLEMS
Identification
 CAGE questionnaire
 Have you ever thought that you should Cut down
on your drinking
 Has anyone Annoyed you by commenting on the
amount you drink
 Have you ever felt Guilty about the amount you
drink
 Do you ever have an Eye opener
Cycle of change
1. Anger at mentioning alcohol
Don’t pursue topic
2. Would like to change but not just yet
Give written information about how to seek help
3. Wants to change now
Use motivational interviewing technique to start
change
4. Already started to change
Reinforce and support change
Barriers to change
 These need to be identified
Motivational interviewing
 People believe what they hear themselves say
 Empathic interviewing style
 Open ended questions
 Reflective listening
 Get on their wavelength
 Feedback about risk
 Agree factual information about personal harm or
impairment
 Balance sheet of pro’s and cons of changing /not
changing
Motivational interviewing
 People believe what they hear themselves say
 Roll with resistance
 Avoid confrontation
 Arguments about terms such as alcoholic are
fruitless particularly in the early stages
 Support self efficacy
 Patient takes responsibility for achieving goals
 Choosing from menu of options
 Encourage belief that change is possible
Motivational interviewing
 People believe what they hear
themselves say
 Reinforce self motivate patients
 Recognition of harm caused
 Desire to change
 Feasibility of change
Withdrawal symptoms
 Common features on stopping alcohol
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Anxiety and agitation
Tachycardia
Sweating
Tremor of extended hands, tongue or eyelids
Nausea and vomiting
Insomnia
Withdrawal fits
Confusion
hallucinations
Withdrawal symptoms
 Should be mild if
 Alcohol free at consultation
 Male drinking < 15units/day
 Female drinking < 10 units/day
 Units of Alcohol
 1 ordinary glass of wine
 ½ pint low strength beer
 1 standard pub short
9/bottle
Withdrawal symptoms
 Management – mild symptoms
 Rest
 Relaxation
 Reassurance that they will pass in a few days
 Explanation – they are evidence of that the brain
has adapted to living in an alcoholic environment
and will take time to readjust to one that is alcohol
free
Withdrawal symptoms
 Need for specialist or hospital referral
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Confusion
Hallucinations
History of fits or epilepsy
Risk of suicide
Failed home detox
Poor nutrition
Unsupportive home environment
Acute physical or psychiatric illness
Any symptoms of encepalopathy
Wernicke’s encepalopathy
 Signs
 Confusion
 Ataxia
 Opthalmoplegia
 Nystagmus
 Coma
 Hypotension
 Hypothermia
 Any unexplained neuro signs during withdrawal
Wernicke’s encepalopathy
 Require urgent specialist
assessment
 Urgent treatment with
parentral thiamine (Pabrinex
IM )
Drug treatment
 Drug of choice for withdrawal are
benzodiazepines
 Can induce temporary problems with cognition
and recall
 Are addictive if taken over time
 Detox with benzos should not be continued for
more than 7 days
 Start with high dose chlordiazepoxide 120mg/day
or diazepam 20mg/day
Detoxification regimen
Ritson, B. BMJ 2005;330:139-141
Copyright ©2005 BMJ Publishing Group Ltd.
Other support
 Patients and family should be advised
 To stay off work
 Not drive
 Rest
 Drink plenty of fluids – fruit juice rather than
stimulants such as cafeine
 Abstain from alcohol
Other support
 Community nurse of GP should visit daily to
 Monitor progress
 Review drugs
 Assess mental state and vital signs
 Breathalyse for alcohol if possible
 Patient may think they can now handle alcohol
must make it clear that drinking must not be
resumed
Daily check
 Tremor
 Pulse
 Temperature
 Blood pressure
 Level of consciousness
 Orientation
 Dehydration
Vitamins
 If well nourished with moderate alcohol
dependence no vitamins required
 If under nourished or frequent relapse or self
neglect
 Then 200-300mg thiamine a day for 2-3
months will help minimise risk to brain and
peripheral nervous system
 May need parental admin during early stages
of detox
Preventing relapse
 Triggers to relapse
 Environment
 Availability
 Pub atmosphere
 Custom
 Always drinks at certain times, occasions and
situations
 Interpersonal
 Stress
 conflicts
Preventing relapse
 Triggers
 Intrapsychic
 Expectations
 Anxiety
 Social phobias
 Depression or elation
 Overconfidence
 Feeling good
 I have got over my drinking problem
 I can take some alcohol again
Preventing relapse
 Drinking diary
 Balance sheet of good and bad consequences
of continued drinking
 Patient should set own goals
 Monitor progress
 Identify ways of dealing with triggers to
relapse
Preventing relapse
 Pharmacotherapy
 Disulfiram
 Blocks metabolism of alcohol flooding the body with
toxic acetaldehyde which causes flushing,
palpitations, nausea, faintness and even collapse
 Start with 200mg/day can be increased to 400mg
 Contra indicated with liver disease, cardiovascular
disorders, pregnant women, suicidal patients or
those who are cognitively impaired
 Only effective if use is supervised
Preventing relapse
 Pharmacotherapy
 Acamprosate
 Helpful adjunct to psychological
therapies.
 Start as soon as abstinence is achieved
 Can be continued during relapse
 can be continued for 1 year
Preventing relapse
 Drug treatments should always
be accompanied by
psychological support and
therapy aimed at attaining a
longer term change of lifestyle
that is drug free