Transcript ALCOHOL USE DISORDERS

Management of substance use
related disorders in primary care
2nd October 2010 – PEMSA Reunion meeting
Dr. E K Rodrigo
MBBS,MD, FRCPsych, FSLCP
& FRANZCP
Senior Staff Specialist in Psychiatry
ACT MENTAL HEALTH
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Clinical suspicion
Assume all patients have an alcohol and /or
tobacco use problem unless proved otherwise
Ask all health care patients about their alcohol
and tobacco use
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HARM ASSOCIATED WITH ALCOHOL USE
•Most drinkers (73%) generally consume alcohol in ways
considered a low health risk (AIHW, 2002).
• Harmful/hazardous alcohol use and dependence is
estimated to cost the Australian community $7.6 billion in
direct and indirect costs (Collins & Lapsley,2002).
•Single episodes of alcohol intoxication contribute to
67% of potential years of life lost (PYLL) due to
premature alcohol-related mortality (CDHAC, 2001).
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ICD-10 criteria for the alcohol dependence
syndrome
3 or more of the following manifestations should have occur together for at least 1
month or if persisting for periods of less than one month should have occurred
together repeatedly within a 12 month period
 A strong …… compulsion to consume alcohol
 Impaired capacity to control drinking
 A physiological withdrawal state
 Evidence of tolerance
 Preoccupation with alcohol,;
 Persistent alcohol use despite clear evidence of harmful consequences,
WHO-1993
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THE CAGE QUESTIONNAIRE
Ever felt to Cut down your drinking ?
People Annoyed you by criticizing your
drinking ?
Ever felt Guilty about your drinking ?
Ever had a drink first thing in the morning as an
Eye opener ?
 Two or more positive replies identify problem drinkers; one is an
indication for further enquiry about the persons drinking.
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DIAGNOSTIC FEATURES
SIGNS OF HARMFUL ALCOHOL USE
HEAVY ALCOHOL USE
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GAMA GT
MCV
Carbohydrate deficient transferrin
CDT
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Cont…..
MANAGEMENT GUIDELINES
ESSENTIAL INFORMATION FOR
PATIENT AND FAMILY
 1-alcohol dependence is a serious illness.
stopping or reducing alcohol use will bring
mental and physical benefits
 2-drinking during pregnancy can harm the
baby
 3-in some cases of harmful alcohol use
without dependence, controlled or reduced
drinking is a reasonable goal
 4-for patients with alcohol dependence,
abstinence from alcohol is the goal.
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SPECIFIC COUNSELLING TO PATIENT
AND FAMILY
1)For those willing to stop now
– Set a definite day to quit
– Discuss strategies to avoid or cope with high-risk
situations (e.g.. social situations, stressful events)
– Make specific plans to avoid drinking use (e.g.. ways
to manage stressful events without alcohol, hoe to
respond to friends who still drink)
– Identify family or friends who will support stopping
alcohol use
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Cont……….
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SPECIFIC COUNSELLING TO PATIENT AND
FAMILY
1-for those willing to stop now:
Set a definite day to quit
Discuss strategies to avoid or cope with high risk
situations
Makes specific plans to avoid drinking use
Identify family or friends who will support
stopping alcohol use
2-if reducing drinking is a reasonable goal
(or if patient is unwilling to quit)
Negotiate a clear goal for decreased use
Discuss strategies to avoid or cope with high risk
situations
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cont….
2)if reducing drinking is a reasonable goal (or if patient is
unwilling to quit)
– Negotiate a clear goal for decreased use (No more than two
drinks per day with two alcohol free days per week )
– Discuss strategies to avoid or cope with high risk situations
(eg: social situations ,stressful events)
– Introduce self monitoring procedures and safer drinking
behaviors. (time , slowing down drinking)
3) For patients not willing to stop or reduce use now :
– Do not reject or blame.
– Clearly point out medical and social problems caused by
alcohol.
– Make a future appointment to discuss drinking.
4) Self- help organizations. (e.g. ;Alcoholic Anonyms) are often
helpful.
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Elements of brief intervention
Present screening results
Identify risks and discuss consequences
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ELEMENTS OF TREATMENT
Motivation
Engagement
Detoxification
Abstinence
Rehabilitation
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IN- PATIENT DETOXIFICATION
Current severe withdrawal
History of severe withdrawal
Imminent withdrawal
Illnesses. pneumonia, pancreatitis
Poly drug use
Suicidal ideation / severe depression
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Community based detoxification
Out patient
Home based
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More acceptable
More accessible
As safe and effective
Cheaper
Than in-patient
treatment
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PHARMOCOLOGICAL THERAPIES
DETOXIFICATION
– BENZODIAZIPINES
AVERSION AGENTS
– DISULFIRAM
CRAVING REDUCTION AGENTS
– NALTREXONE
– ACAMPROSATE
SSRI
– FLUOXETINE
DOPAMINE AGONISTS
– BROMOCRIPTINE
– TIAPRIDE
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Advise patients not to drink
When operating a machinery or vehicle
When pregnant or considering pregnancy
If a contraindicated medical condition is
present
After using certain medications, such as
sedatives, analgesics, and selected
antihypertensive
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VISUAL AID A 4
ADVICE TO INDIVIDUALS
1) As a general rule, not more than 2 drinks in any day
2) Lower levels are appropriate for specific groups
3)Current abstainers are advised not to begin drinking in order
to reduce health risks
5) Those who drink more than 2 drinks a day are advised to cut
down
6) One drink-free day per week is recommended to minimize
risk of dependence
7) It is advisable to avoid intoxication
8) Pregnant women are advised to abstain
9) In certain circumstances it is best not to drink at all
10)People considering increasing their drinking should consult
the doctor first
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What’s a low risk limit
No more than two standard drinks a day
Do not drink at least two days of the week
But remember: there are times when even one or two
drinks can be too much-for example:
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When driving or operating machinery
When pregnant or breast feeding
When taking certain medication
If you have certain medical conditions
If you cannot control your drinking
Ask your health care provider for more information
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WORKING WITH ILLITERATE
PATIENTS
Patients who are illiterate or have poor reading
ability will require special help in brief
counseling situations. it's recommended that the
health care worker review the self-help booklet
with the patient, assist in filling out the plan, and
(if the patient is willing) suggest that the patient
give the materials to a family member or a
friend who might assist in reminding the patient
of it’s contents.
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Cont…..
Medication
1) Withdrawal from alcohol may require use
of anti- anxiety drugs (Benzodiazepines,
e.g.: lorazepam .5 to 2 mg up to) but out
patient use should be closely monitored
2) Disulfiram may help to maintain abstinence
from alcohol in some cases, but routine use
is not necessary
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SPECIALIST CONSULTATION
Severe alcohol withdrawal ( with hallucinations
and autonomic instability) may require
hospitalization, and use of higher dose antianxiety drugs.
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WEIGHING UP THE PROS AND CONS
Why I want to
stop smoking
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Why I enjoy
About smoking
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Where does that leave me now ?
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PROBLEM PREDICTOR
On the first day:
The biggest problem will be
------------------------------------------------------------------------------------------------------------The solution is…
------------------------------------------------------------------------------------------------------------During the first week:
The biggest problem will be..
------------------------------------------------------------------------------------------------------------The solution is..
------------------------------------------------------------------------------------------------------------Other problems during the first week..
------------------------------------------------------------------------------------------------------------Solutions..
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TOP STOP TIPS
Something in your mouth
Do something with your hands
(find something to fiddle with-a pencil, coin, worry
beads..)
Don’t forget the habit-breaking principle
Save your cigarette money
Set up a special savings account
Something to remind you
(clean out an old jam jar and fill it with cigarette butts)
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MANAGEMENT GUIDELINES
Essential information for patient and family
1) any amount of tobacco use may have
harmful health effects
2) using tobacco during pregnancy may harm
the baby
3) discontinuing tobacco use should improve
health now and in the future
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Cont…
Specific counseling to patient and family
1) for patients now willing to quit
– Set a definite date for quitting
– Discuss high risk situations for resuming tobacco use (e.g.
socializing with friends who use tobacco)
– Make specific plans to avoid resuming tobacco use (e.g.
discuss how to respond to friends who offer cigarettes)
– Identify friends or family members who support stopping
tobacco use
2)for patients not now willing to quit
– Do not reject or blame
– Clearly point out current and future health effects of
continued tobacco use.
– Make a future appointment to discuss tobacco use
3)group counseling programs may be helpful if available
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Cont…
MEDICATION
Nicotine preparations may help reduce nicotine
withdrawal symptoms. these should not be used
without counseling described in #1 above
Bupropion
Varenicline
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Enhancing Motivation to Quit Tobacco: the 5 Rs*
Relevance
Risks
Rewards
Roadblocks
Repetition
Special treatment for drinking
problems
 Psychological treatment
Motivation interviewing
Broad spectrum cognitive – behavior
approaches
Relapse prevention and community
reinforcement.
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Cognitive – behavioral techniques
Anxiety management
Anger management
Skills training
– Social
– Problem solving
– Drink refusal
Behavioral control training
Cue exposure
Marital and family therapy
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HIGH RISK SITUATION EMERGENCY
PLAN
I will leave/ change situation
I will put off decision to drink by 15 minutes
I will change my thoughts
I will think of some thing else
I will remind myself of my success
I will call for help
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MANAGING COMMON THOUGHTS LEADING TO
RELAPSE
Escape
Relaxation
Socialization
Improved self image
Romance
To hell with it
No control
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Motivation enhancement
Express empathy
Develop discrepancy
Avoid argumentation
“Roll” with resistance
Support self efficacy
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Coping with craving / urges
Recognize triggers
Exposure to alcohol
Seeing other’s drink
Contact with
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People
Places
Times of day
Situations
Emotions-frustration
Physical states
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The evidence for brief intervention
Bien,et al 9.- considered 32 controlled studies
involving 6000 patients, finding that brief interventions
were often as effective as more extensive treatment
Kahan, et al 10.-the public health impact of brief
intervention is potentially enormous
Wilk, et al 11.-drinkers receiving a brief intervention
were twice as likely to reduce their drinking over 6-12
months than those who received no intervention
Moyer et al 12.-brief intervention should not substitute
for specialist treatment. they might well serve as an
initial treatment for severely dependent patients
seeking extended treatment.
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Department of Health Webpages
http://www.health.gov.au/internet/main/publishing.nsf
/Content/phd-aodgp
http://www.health.gov.au/internet/main/publishing.
nsf/Content/portal-Alcohol
http://www.health.gov.au/internet/main/publishing.
nsf/Content/tobacco-res
http://www.health.gov.au/internet/main/publishing.
nsf/Content/portal-Tobacco
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