Dr Noel Plumley Addiction Medicine Specialis t
Treatment Modalities Detoxification Relapse Prevention Harm Reduction
Detoxification is Not Treatment It is important to note that ‘detoxification’ or withdrawal management is not treatment per se of alcohol dependence, rather, it is a clinical intervention to address acute risks associated with the pathophysiology of neuro adaptation reversal & … open the door to ‘treatment’ Withdrawal management sets the scene for definitive treatment, for example, cognitive or behavioural therapy In the absence of detoxification, it may be unworkable & indeed unsafe & unrealistic to attempt behaviour change in a patient who is dependent, alcohol affected in cognition & behaviour & continuing to drink to prevent or mitigate daily withdrawal symptoms
Substances of interest ALCOHOL OPIOIDS AMPHETAMINES CANNABIS BENZODIAZEPINES NICOTINE
Substances of Interest ALCOHOL OPIOIDS AMPHETAMINES CANNABIS BENZODIAZEPINES NICOTINE
Low risk drinking level ( There is actually no safe level) NHMRC Australian guidelines to reduce health risks from drinking alcohol (2009): 1. For reduced lifetime risk of harm from drinking: 2 standard drinks or less in any 1 day (for healthy men and women, aged 18 and over) 2. For reduced risk of injury in a drinking occasion: No more than 4 standard drinks per occasion 3. For people <18 years of age: safest not to drink Under 15: Especially important not to drink Between 15-17: Delay drinking initiation for as long as possible 4. Pregnant (or planning a pregnancy) or Breastfeeding: Not drinking is safest option
W hat is a standard drink? NB: Home or restaurant poured drinks are variable but are typically 2-3 standard drinks
Non-standard drinks
Non-standard drinks Check rate of purchase of bottle/flagon Assess by packaged units (e.g. number of bottles of wine or spirit purchased per week) Get patient to pour what thy think is a standard drink. You may get a surprise!
Types of drinkers ( adults) High risk/dependent 5-6% At risk 15% Low risk 65% Non-drinker 15% Teesson, 2000 ANZ J Psych, 34 (NSMHWB)
Picking up on the signals Lesson: If a patient presents to doctor with alcohol on breath, they have an alcohol problem unless & until proven otherwise If a patient says ‘ Its OK Doc, I can hold my grog ’ , that ’ s in no way reassuring “I only have a social drink” is meaningless. The amount of alcohol and frequency must be quantified Good clinical practice would be to ask about drinking & offer help
Picking up on the signals Deciding what is required & where Brief intervention supported by evidence If detoxification is indicated, consider home based Rx if: no history of complications in withdrawal no medical or psychiatric contraindications home environment is suitable, supportive, safe & compliance is considered likely Otherwise, inpatient setting is indicated
Drinking History Assessment CAGE : not useful for detecting early problems Ditto laboratory markers AUDIT 92% sensitivity/ 90%+ specificity in PHC setting 2 ‐ 3 mins to administer Good clinical utility for problem identification Severity of Dependence Scale DSM ‐ 5 dependence AWS Withdrawal Rating Scales
Using CAGE for Alcohol Screening* 1. Have you tried cutting down your drinking? 2. Have you felt annoyed by other’s comments on your drinking? 3. Does your drinking cause you to feel guilty? 4. Do you drink first thing in the morning (‘eye- opener’)? ≥ 2 positives suggests problem Limited clinical utility for early intervention – ‘horse has bolted’ May be helpful in others
AUDIT Qs 1 ‐ 3: Hazardous consumption Qs 4 ‐ 6: Dependence symptoms Q 7 ‐ 10: Harmful drinking
AUDIT Frequency of drinking 1. Typical quantity 2. Frequency of heavy drinking 3. Impaired control over drinking 4. Increased salience of drinking 5. Morning drinking 6. Guilt after drinking 7. Blackouts 8. Alcohol ‐ related injuries 9. 10. Others concerned about drinking
Single Question Screening When time is limited in a clinical setting: ASK: In the last year have you had 6 or more standard drinks on 1. a single occasion? BRIEF ADVICE based on response or refer … 2. Recent study (Vitesnikova, 2013) suggests best single question, at least in a hospital trauma dept. setting is Q2 of the AUDIT: How many std drinks do you have on a day when you are drinking? O 1 or 2 O 3 or 4 O 5 or 6 O 7 ‐ 9 O ≥ 10 A score ≥ 2 suggests there may be a drinking problem
Som e definitions Hazardous use: drinking patterns that increase the risk of adverse consequences for the user or others Harmful use: already experiencing consequences to physical or mental health from drinking Could also include social consequences Babor et al, 2001, WHO
Som e definitions Dependence – ICD10 (DSM V & WHO are similar) Three or more criteria present: Compulsion to drink Loss of control Tolerance Salience/neglect of alternative interests or obligations Withdrawal symptoms Persistent drinking despite harm ( Ease of relapse) WHO, 2007
Assessing Alcohol Neuroadptation Can assess level of neuroadaptation from clinical status matched to BAL If present with BAL ≥ 0.1g% & not clinically intoxicated, this signals significant neuroadaptation, tolerance & therefore more likely a clinically significant withdrawal syndrome If not affected at ≥ 0.2g%, likelihood increases substantially
Severity of Dependence Scale These questions are about your use of DRUG in the last year. 1. Did you ever think your DRUG use was out of control? Never/almost never Sometimes Often Always/nearly always 2. Did the prospect of missing the DRUG make you very anxious or worried? Never/almost never Sometimes Often Always/nearly always 3. Did you worry about your DRUG use? Not at all A little Quite a lot A great deal 4. Did you wish you could stop? Never/almost never Sometimes Often Always/nearly always 5. How difficult would you find it to stop or go without? Not difficult Quite difficult Very difficult Impossible Score: /15 N.B. Each of the five items is scored 0, 1, 2, 3, resulting in a total score of 0 to 15.
W hy the definitions are im portant Dependent drinkers usually need to stop drinking and may experience a withdrawal syndrome, esp. on awakening Hazardous or harmful drinkers can usually cut down
Alcohol & ICD ‐ 10 Diseases Alcohol consumption is causally linked to a large number of disease outcomes: Thirty 3 ‐ digit or 4 ‐ digit codes that are alcohol ‐ speci fi c & >200 ICD ‐ 10 3 ‐ digit disease codes in which alcohol is a component cause, in addition i.e. alcohol causes & contributes to more than 60 commonly identified medical conditions
Chronic Com plications GI: liver, dyspepsia, diarrhoea, delayed healing of peptic ulcer, pancreatitis Psychiatric: depression, suicide Neurological: cognitive impairment, Wernicke/Korsakoff’s, neuropathy, stroke CVS: hypertension, cardiomyopathy, arrhythmias
Chronic com plications Nutritional: thiamine, folate, B12, malnutrition Musculoskeletal: osteoporosis, myopathy Immune: ↓ T-cell function Respiratory from associated smoking, TB Renal: electrolyte disorders Endocrine: cortisol, ↓ testosterone, type 2 diabetes Cancer: aerodigestive, breast, rectum Fetal development: fetal alcohol syndrome
Early sym ptom s and signs of chronic alcohol problem s Hypertension Insomnia Indigestion/diarrhoea Anxiety Depression Sick days
Alcohol induced liver disease Overlapping processes: Fatty liver Reversible Alcoholic hepatitis Severe cases rare Cirrhosis Largely irreversible 15% persons drinking 150g/d for 10+ yrs
W hy does alcohol cause organ dam age? Multiple factors, varies between organs Harmful consequences of metabolism Oxidative (acetaldehyde toxicity, oxidant stress, acidosis) Non-oxidative (fatty acid ethyl esters damage membranes) Nutritional impairment Endotoxinaemia Abnormal gut absorption of bacterial products
Alcohol Laboratory Markers Gamma Glutamyl Transferase GGT ALT/AST Mean Red Cell Volume MCV Platelets Carbohydrate Deficient Transferrin CDT
Predicting Withdrawal Severity Up to 30% acute hospital medical admissions are at risk of alcohol withdrawal Rule of thumb: risk of significant withdrawal syndrome at ≥ 8 drinks/ day over X years & … Risk of seizures & other complications at ≥ 150g/ day Withdrawal emerges when BAL falls – sometimes from as high as 0.15g%+ May start loading with diazepam at this level when risk is assessed as moderate to severe Withdrawal peaks within 24 ‐ 72 hr after last drink Usually lasts 5 ‐ 7 days DTs more protracted (up to 14 days+)
Alcohol Withdrawal Symptoms may include: Chills, Sweats, or high temp Anxiety or panic attacks Shakes or Jitters Chest pain Headache Nausea or vomiting Abdominal pain Paranoid delusions or illusions Auditory & visual hallucinations
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