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New care pathways for managing
dependent drinkers
Dr James Bell
Ms Fiona Kennedy
Ms Chris Healey
Dr Mohammad Faizal
Dr Lynn Owens
Dr Sreedharan Nagendran
Dr Steve Hood
Why is this research important?
• Over the last 2 decades there has been a measureable increase in
alcohol-related liver disease, and a more difficult to measure
increase in other adverse consequences of alcohol dependence.
Alcohol-related diseases and social marginalisation place a large
burden on the NHS.
• There has been limited integration of addiction services, hospitals
and primary care. A recent report (NCEPOD 2013) has called for the
establishment of consultant-led teams of alcohol nurses in general
hospitals to try to manage alcohol better, and provide an opportunity
to intervene to minimize the future burden of disease resulting from
alcohol misuse. In the light of this recommendation, it is useful to
evaluate some innovative alcohol pathways that have been
developed in recent years.
Aims and Objectives:
•
To describe two acute care pathways for dependent drinkers presenting to
ED:
1)
2)
•
To compare characteristics (demographics, severity of dependence, GGT
values (proportion abnormal), prior Rx history of patients attending these
pathways with people presenting for elective management of alcohol
dependence:
1)
•
•
Hospital liaison service and ambulatory clinic (LCAS, Royal Liverpool)
Hospital liaison service and immediate transfer to IP unit (AAU unit, London)
Elective detoxification clinic (Windsor Clinic, Liverpool)
To compare the outcomes of the acute and elective pathways in terms of
time to first drink post treatment, attendance for aftercare, and presentation
to ED in the 3 months after treatment
We also sought to identify potential predictors of good outcomes.
Sampling:
Windsor Clinic
AAU Unit
LCAS
77 Participants
recruited
50 participants
recruited
46 participants
recruited
Telephone Interviews
conducted with 57/77
participants (74%)
Telephone Interviews
conducted with 17/50
participants (34%)
Telephone Interviews
conducted with 26/46
participants (57%)
Research Outcomes
Demographics:
•
Demographically, participants from all three pathways were very similar:
• Mean age – 45
• Majority of participants were male (around 70%)
• Majority of participants at all three pathways were unemployed.
• Most of the participants were single.
Drinking history and alcohol dependence:
•
•
Most participants drank between 200 and 250 units of alcohol per week on
admission. Participants who were admitted to the AAU unit tended to consume a
larger number of units of alcohol per week than those at LCAS or the Windsor
Clinic.
Most participants at all three pathways had a severe dependence on alcohol
according to the SADQ model (31+). The SADQ scores recorded for participants
were higher at the Windsor Clinic than the other two pathways.
Concomitant mental and physical history:
•
•
•
41% of participants were prescribed anti-depressants.
24 % of participants had a history of self harm. Participants who were recruited
from the London pathway were significantly more likely to have a history of self
harm than those recruited from either the Windsor Clinic or LCAS.
39% of participants had a history of seizures. Participants who were recruited
from the KHP pathway were also significantly more likely to have a history of
seizures.
Treatment Process:
•
Most participants completed detox and were referred aftercare (either within the
unit or in the community).
Three month follow up:
•
•
•
•
Self reported abstinence at 3 month follow up (if assuming that
participants we were unable to get hold of have relapsed), 30% of
participants who had been treated at the ambulatory detox pathway
(LCAS) were still abstinent 3 months post treatment, 12% from London,
18% from Windsor Clinic.
18% of participants who had been treated at Windsor Clinic had
relapsed within 8 days of leaving treatment, while at London this was
slightly lower (but still significant) at 10%. At LCAS, this accounted for
4% of participants.
For those participants who had relapsed within 8 days of being
discharged, the number of times they attended ED significantly
increased in the 3 month period post treatment.
35% of participants attended aftercare. Participants were much more
likely to have attended aftercare if they were treated on the ambulatory
detox pathway (LCAS). The LCAS team offered their own aftercare in
the form of alcohol clinics within the hospital. This was not offered by
either of the other two pathways.
Qualitative Findings (3 month follow up
telephone interviews):
• The majority of participants found the treatment helpful.
• The most commonly reported positive aspect of the care
was the staff.
• Although most participants found the treatment helpful,
they did suggest ways that it could be improved. These
included:
1) More readily available aftercare
2) Longer treatment
3) Medication for longer
Implications for future research:
• Demographically, patients were very similar at all three
pathways.
• The ambulatory detox model is as successful as in-patient
detox in terms of hospital readmission within 3 months but
seems to be more successful in terms of abstinence rates.
Participants were much more likely to have remained abstinent
after 3 months if they had attended the ambulatory detox
model.
• However, ambulatory detox is not suitable for all patients.
Some will still need inpatient treatment.
• A lot of patients relapsed after inpatient detox within 1 week.
Implications for future research (2):
• We now propose conducting a quality-improvement initiative study
combining some parts of the ambulatory detox model with inpatient
detox programs to try and improve abstinence rates.
• This will be done at Windsor Clinic in Liverpool and the AAU unit in
London and will include:
1) A doctor will see the patient 24 hours prior to discharge to
discuss follow up plans and arrange an appointment
2) The patient will then be seen by an already familiar doctor/nurse
within 3 days of discharge.
3) Depending on clinical need, patients will be seen again 1 week
later, then 3/4 weeks later.
4) Further follow up management (if required) such as support from
community agencies and prescribing medication, then this will be
initiated at the earliest opportunity.
Service Evaluation
Anti-Craving Clinic
Windsor Clinic
Number of Patients evaluated: 102
Demographics
Gender
• 51% of the patients were male.
• 49% were female.
Age of Patients
• Mean – 46
• Minimum – 25
• Maximum – 70
Alcohol Dependency
The majority of patients who were
commenced on anti-craving
medication (80.5%) had a severe
dependency on alcohol.
Prior History of Alcohol detox’s
Nearly 80% of the patients who were
commenced on anti-craving medication had
previously been an inpatient at the Windsor
Clinic. 48% of all patients had attended the
Windsor Clinic only once in the past, however
some patients had stayed at the Windsor Clinic 5
times or more (6%).
Co-morbid Medical History
Nearly 80% of patients suffered from a mental
health problem:
• 48% of patients suffered from depression
• 30.3% of patients suffered from anxiety
• 16.6% of patients had self-harmed in the past
36% of patients had a pre-existing physical
health condition.
Use of Anti-Craving medication
Patients were commenced on either
Acamprosate, Disulfirum or Naltrexone:
Medication
No of patients % of patients
Acamprosate
78
76.5%
Disulfirum
12
11.8%
Naltrexone
12
11.8%
Abstinence Rates
40% of patients remained abstinent throughout
the anti-craving treatment:
Time period
< 1 month
< 2 months
< 3 months
Over 3 months
Still Abstinent
No of patients
16
13
11
21
41
% of patients
15.7%
12.7%
10.8%
20.6%
40.2 %
Alcohol
•
•
•
•
•
•
•
Toxic and dependant drug
Mood effect
Aggression and violence
Coma, respiratory depression, death, drowsiness
Psychiatric disorders
Associated with a number of physical illness
3rd leading cause of disability after tobacco and
hypertension
• Memory problems
NICE Guidance
Diagnosis and clinical management of alcohol related physical
complications (CG100)
Diagnosis, assessment and management of harmful drinking
and alcohol dependence (CG115)
Medications for relapse prevention
Effective, but limited use
• Acamprosate and Disulfiram licensed in UK
• Naltrexone only recently licensed in UK but widely
used elsewhere (e.g. US, Australia)
• Nalmefene recently licensed
• Not licensed in under 18s or pregnancy
• Precise mechanisms of medications not fully
understood
• Baseline U&E and LFTs , FBC, ECG
• Should be used in conjunction with psychosocial
interventions
• Compliance issues
Brain Chemistry
Dopamine increase - pleasurable effect of alcohol
Reward pathway
Alcohol dependence – dopamine system responds to
cues & motivates to drink
Increased dopaminergic activity – encourages person to
seek alcohol ( ? craving )
Role switches from pleasure to alcohol seeking
Opioids
Alcohol increases opiates in brain
This in turn increases the dopaminergic activity
Opioid blockers – naltrexone , nalmefene
GABA – Inhibitory or calming system in the brain
GABA –B stimulation reduces dopaminergic activity in the
brain ( Baclofen )
GABA –A stimulation increases inhibitory system ( BDZ/
LIBRIUM )
Serotonergic system – effect of alcohol on it not fully
understood
Consistent demonstration of reduced serotonergic activity
Acamprosate
NMDA ( glutamate systems ) antagonist, GABA agonist
19 RCTs; high quality
Moderate to severe dependnece
PSI interventions used ( alcohol counselling, medication
management, relapse prevention )
Superior to placebo in abstinence and relapse to heavy drinking
( meta analysis )
Most studies conducted in Europe with one in UK
Commenced soon after withdrawal or during assisted
withdrawal
Abstinence effect most pronounced at 6 months but remained
significant up to 12 months
Numbers relapsing to heavy drinking was also significantly less
in acamprosate group
NICE – The Quality of evidence for acamprosate is high
Start after withdrawal; dose 1332-1998mg
Continue up to 12 months, monthly supervision
Side effects: diarrhoea, abdominal pain, nausea vomiting,
pruritis
Contraindicated: pregnancy, breast feeding, renal and hepatic
failure
Start ASAP after withdrawal period
Takes 5 days to reach steady blood levels
? improve sleep due to its glutamate activity
Disulfiram
Aldehyde dehydrogenase blocker
Start 24 hrs after detox
Dose : 200mg
• Side effects: interactions with alcohol, wide range of drugs,
drowsiness, nausea, vomiting, halitosis, loss of libido
psychotic reactions, peripheral neuritis, liver failure
• Contraindications: renal failure, hepatic or respiratory,
diabetes, severe personality disorder, suicide risk, psychosis
Evidence : Very few good quality studies available
NICE: Decided to use open label studies due to lack of good
quality RCT
Ethical issue – Due to ethanol – alcohol interaction, studies had
to be open label
3-4 trials in meta analysis
Most studies in US, 2 in India , I in UK
Most studies are old and poor quality
Likely to increase the time until participants drank any alcohol
and number of abstinence days in comparison with naltrexone
and placebo.
Psychological effect of knowing they were taking disulfiram may
have contributed to above effect
NICE : Quality of effect is moderate
Start at least 24 hours after the last alcoholic drink
Naltrexone
Opioid antagonist ( Not to prescribe if on opiates )
27 RCTs; high quality
Superior to placebo in relapse to heavy drinking and no. heavy
drinking days
Start after withdrawal; dose 25 -> 50mg
Continue up to 12 months, monthly supervision
Side effects: nausea, abdominal pain, reduced appetite, tiredness,
hepatotoxicity in high doses, opioid blockade
Higher dropouts
Contraindications: liver failure, renal failure, opioid medication
Mild to moderate dependence (acamprosate group had more
severe dependence )
NICE – Quality of evidence high
Start ASAP after withdrawal period
Baclofen
GABA –B agonist
Muscle relaxant , treat spasticity
High doses can cause ataxia , drowsiness ( above 80mg )
?Baclofen withdrawal syndrome
? recreational use
Gradual titration recommended
Overdose baclofen
Prominent features are signs of central nervous depression
eg drowsiness, impairment of consciousness, respiratory
depression, coma. Also liable to occur are confusion,
hallucinations, agitation, accommodation disorders, absent
pupillary reflex; generalised muscular hypotonia, myoclonia
hyporeflexia or areflexia; convulsions; peripheral vasodilation,
hypotension, bradycardia; nausea, vomiting, diarrhoea,
hypersalivation; elevated LDH, SGOT and AP values.
A deterioration in the condition may occur if various
substances or drugs acting on the CNS eg alcohol, diazepam,
tricyclic antidepressants, have been taken at the same time.
Symptoms may occur at lower dosages in patients with
impaired renal function or in the elderly.
Note
Not everyone benefits from pharmacology
Predictors of outcome – difficult ( post hoc analyses looking at
outcomes and clinical variables )
Conclusion : acamprosate is potentially effective for anyone
with dependence
How long to continue
Most trials between 3 and 6 months
Many relapse within months to years
Limited evidence to guide the length of treatment
Stop if dependant pattern (acamprosate & Naltrexone)
Disulfiram – discontinue if any evidence of drinking
Continuation beyond 1 year need to be justified