Alcohol (Part 2) Management © 2009 University of Sydney.

Alcohol (Part 2)Management

© 2009 University of Sydney

Learning outcomes

To be able to provide:• Management of hazardous and harmful

drinking:– Screening– Brief intervention

• Management of dependence– Motivational interviewing– Withdrawal management– Relapse prevention– Monitoring– Harm reduction

Case study

• Chloe is a 38 year old new patient who presents requesting a script for an anti-hypertensive.

• When you take an alcohol history you discover she drinks 3 cans of beer most nights of the week with up to six glasses of wine on a Saturday.

Questions• What should she do about her drinking? What

goals should she aim for?• How will you help convince her to change her

drinking?

Screening for alcohol problems

• Screen every patient– Validated questionnaires e.g. AUDIT,

CAGE

• AUDIT-C (AUDIT items 1-3)– Asks patient how much and how often they

drink:• Quantity• Frequency• Episodic heavy drinking, eg Saturday nights

AUDIT-C

Questions

Scoring systemYour score0 1 2 3 4

How often do you have a drink containing alcohol?

NeverMonthlyor less

2 - 4 times per month

2 - 3 times per

week

4+ times per

week

How many units of alcohol do you drink on a typical day when you are drinking?

1 -2 3 - 4 5 - 6 7 - 8 10+

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?

NeverLess than monthly

Monthly WeeklyDaily or almost daily

A total of 5+ indicates increasing or higher risk drinking.An overall total score of 5 or above is AUDIT-C positive.

Brief intervention

• Proactive detection of drinking problems• Advice or counselling at the point of

detection• Used for non-dependent (hazardous and

harmful) drinkers• Also to help engage/motivate dependent

drinkers

Especially for non-dependent drinkers

Early intervention

• Screening, and brief (5-20 minutes) structured advice at point of detection

• Significant reduction in alcohol consumption at 6-12 month follow-up– In a non-treatment seeking

population

Moyer et al, 2002, Addiction, 97(3): 279-292. © 2002 Wiley-Blackwell.

Mean of 34 studies

Effect Size

Early and brief intervention

Components of Brief Intervention: ‘FLAGS’– Feedback– Listen– Advice– Goals – Strategies

Bien et al, 1993, Addiction, 88

Especially for non-dependent drinkers

Brief intervention

• Feedback: – evidence of harm experienced from drinking– Or risks faced if drinking continues at this

level

• Listen: – to whether the patient is prepared to consider

changing their drinking– or whether perhaps they have tried to change

it many times before

Brief intervention• Feedback• Listen• Advice: clear advice that they

should cut down

• Goals : what should they be aiming for?

• Strategies: practical ways of changing drinking

Strategies for reducing drinking

• Planning an alternative activity • Limiting time with drinking friends• Switching from schooners to middies• Switching to light beer• Not drinking alcohol for thirst• Eating when drinking• “Excuses” for peers: “getting fit”, “my

doctor told me to cut down”

After brief intervention

• Can provide with self-help brochure

• Consider a drinking diary

• “Feel free to come back to discuss this again/if you need a bit of help”

Withdrawal management

Alcohol withdrawal

• Can deter a drinker from attempting to stop

• Ranges from very mild overnight withdrawal to life-threatening

• Setting of management will be determined by patient preference, safety issues and history of past withdrawals

Timeframe for withdrawal

• Mild withdrawal: even after overnight abstinence e.g. anxiety, mild agitation

• Seizures: peak risk 6-24 hours

• Typical withdrawal: peak at 48 hours

• Withdrawals finish within a week

Timeframe for withdrawal

NSW Drug and Alcohol WithdrawalClinical Practice Guidelines, MHDAO, NSW Health, 2007

Withdrawal rating scale

• E.g. signs of withdrawal scored 0-4: – Perspiration– Tremor– Anxiety– Agitation– Hallucinations– Axillary temperature– Orientation

Example of Alcohol Withdrawal Chart

Withdrawal management

• If withdrawal syndrome likely

– select setting : home, detox unit, hospital

– Monitor with an alcohol withdrawal scale:

• daily as outpatient via GP, or D&A unit

• 4 hourly or more often as inpatient

• Remember the scale is only useful in the absence of other pathology

– Diazepam titrated against withdrawal scale

If AWS reaches threshold (e.g. 5)

• Diazepam titrated against withdrawal scale:– up to 20 mg per dose until returns below threshold

typically up to 20mg qid on day 1 for an inpatient;10mg qid for outpatient (plus 2 x 20mg prn)

– usually oral– Daily dispensing via GP/D&A unit for outpatients

• Check diagnosis is correct – DDx hypoxia, infection

• Remember risks of diazepam (e.g. airways disease; elderly)

Delirium tremens (DTs)

• Risk factors for a severe withdrawal– Duration and severity of dependence– Past severe alcohol withdrawal

syndrome– Medical and surgical events– Anaesthesia– Age

Delirium tremens (DTs)

• Preventable if withdrawal starts in hospital• Significant (15%) mortality if untreated:

– Dehydration, arrhythmias, medical co-morbidity, suicide

• Management– Diazepam

• Generally IV in small doses (e.g. 2mg at 2-5 minute intervals) to prevent respiratory depression

– Haloperidol if hallucinations– Fluid balance– Thiamine IV 100mg tds– Safe environment

Relapse prevention

Relapse prevention

• Medical role – Pharmacotherapy– Maintenance of therapeutic relationship– Monitoring, feedback, support– Assessment of complications

• Mutual support groups, e.g. AA• Counsellor• Residential program ‘rehabilitation’

Pharmacotherapy for relapse prevention

• Naltrexone 50mg mane– Nausea common, start with half dose– Avoid in liver failure and severe

depression– Reduces reinforcement of drinking– Reduces severity of relapses– Warn re opioid blocking effects– Subsidised by PBS Authority: “part of a

comprehensive treatment program”

Either:


• Acamprosate ii tds (reduced if < 60kg)

– May assist in reducing craving– Up to 12 months treatment– Minimal side effects (diarrhoea, pruritus,

rash occasionally)– Start after withdrawal complete– Avoid in renal failure– Subsidised by PBS Authority: “part of a

comprehensive treatment program”

and/ or:

Naltrexone v Acamprosate

• Naltrexone modestly effective.

• Acamprosate effect small and not statistically significant

• No benefit from combining medicationsFigure: Anton et al, 2006, JAMA, 295(17): 2010.

Copyright © 2006 American Medical Association. All rights reserved.

COMBINE study (n=1383)

Disulfiram “Antabuse”• Most effective of available medications if

patient is willing and compliant1

• Works best if dosing is supervised2

• Blocks ALDH activity• Aversive reaction after even a tiny amount

of alcohol: – flushing, palpitations, hypotension,

vomiting, headache• Contra-indications: cirrhosis, heart disease

1Laaksonen, Alc & Alc 20072Chick, Br J Psych 1992

Other medications

• Limited evidence

• Not registered for alcohol treatment

• Baclofen

• Ondansatron

Role of antidepressants

• Many cases of depression resolve with abstinence

• SSRIs: not for drinking per se– If significant depression, can select

an SSRI with less side effect of agitation, e.g. citalopram or sertraline

Harm reduction

• Thiamine: can reduce risk of neurological cx• Duty of care issues

– Driving– Occupation (e.g. train driver, doctor…)– Child protection

• Physical safety issues while intoxicated– Transport home– Risk of violence including sexual assault

E.g. if a heavy drinker can’t or doesn’t want to change drinking

Thiamine

• 100mg tds daily– IM if vomiting, gastritis, very heavy

consumption (unless bleeding disorder)– IV if suspected Wernickes

• (e.g. lateral gaze palsy/nystagmus, delirium, ataxia)

• tds in more severe cases for a week

Summary

• Outcome improves with treatment• Early pro-active detection and

intervention best• Care by D&A specialists not essential

for many drinkers• Withdrawal management possible at

home for many milder cases• New pharmacotherapies improve

duration of remission

Case study• Jane is a 49 year old woman who drinks a small

flagon (500mls) of wine every day. When she tries to stop, she feels very tense and finds she needs a drink to settle herself. On the one time she was admitted for surgery for a week, she required nocte Valium for sleep.

Questions:– Is Jane likely to be dependent?– Is she likely to experience an alcohol

withdrawal syndrome and if so, of what severity?

– Would she be suitable for home detoxification?– What would be the key elements in

management?

Case study - answers

• Jane is likely to be dependent. – withdrawal agitation relieved by drinking– tried to cut down without success (loss of

control)– 5 drinks per day is enough to cause

dependence• Past withdrawal when hospitalised was

very mild, requiring only nocte sedation, hence home detox likely to be possible

• Thiamine; diazepam regime; monitoring; acamprosate; counselling (motivational; CBT; supportive)

Contributors

Associate Professor Kate Conigrave Royal Prince Alfred Hospital & University of Sydney

Dr Ken CurryCanterbury Hospital & University of Sydney

Professor Paul HaberRoyal Prince Alfred Hospital & University of Sydney

Associate Professor Martin Weltman Nepean Hospital & University of Sydney

All images used with permission, where applicable.

Alcohol (Part 2) Management © 2009 University of Sydney.

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Transcript of Alcohol (Part 2) Management © 2009 University of Sydney.