Dr Noel Plumley Addiction Medicine Specialis t Treatment Modalities - - PowerPoint PPT Presentation

Dr Noel Plumley Addiction Medicine Specialist

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

• f wine or spirit purchased per week)

 Get patient to pour what thy think is a standard

• drink. You may get a surprise!

5-6% 15% 65% 15% High risk/dependent At risk Low risk Non-drinker

Teesson, 2000 ANZ J Psych, 34 (NSMHWB)

Types of drinkers ( adults)

Picking up on the signals

 Lesson: If a patient presents to doctor with alcohol on

breath, they have an alcohol problem unless & until proven

• therwise

 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 &

• ffer 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-
• pener’)?

 ≥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

1.

Frequency of drinking

2.

Typical quantity

3.

Frequency of heavy drinking

4.

Impaired control over drinking

5.

Increased salience of drinking

6.

Morning drinking

7.

Guilt after drinking

8.

Blackouts

9.

Alcohol‐ related injuries

• 10. Others concerned about drinking

Single Question Screening

When time is limited in a clinical setting:

1.

ASK: In the last year have you had 6 or more standard drinks on a single occasion?

2.

BRIEF ADVICE based on response or refer … 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

• thers

 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.

• n 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‐specific

& >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

Alcohol Withdrawal

Signs may include:

Blood pressure, Pulse rate & Temperature elevated Hyperarousal, agitation restlessness Cutaneous flushing & or perspiration Dilated pupils Ataxia Tremor Altered level of consciousness or Disorientation Delirium

Progress of the Alcohol Withdrawal Syndrome

Assess Alcohol Consum ption

 Prevention/ early intervention: take a quantified

drinking history from every patient

 Episodic risky drinking is common

 Up to 40% Aus adults report drinking in excess of

NHMRC Guidelines (2009)

 Make it easy for the patient to admit to heavy drinking

 e.g. can suggest a high level of drinking as a starting point

because patients may not feel comfortable revealing level of consumption if you communicate your assumption or hope that patient is drinking in low risk manner

Assessm ent of drinking

 Consumption level & pattern  Indicators of dependence  Desire to change drinking, past attempts  Complications/comorbidity

 Physical & psychiatric problems

 e.g. hep C, obesity

 Other substance use

 Benzodiazepines, opioids (licit/illicit), cannabis,

stimulants, other prescribed psychotropics

Drinking History Assessment

 Quantity  Frequency  Pattern  Duration

 Typical day of drinking  Last 7 days  Assess severity & complications of previous

withdrawal (seizures, DTs)

 Note ‘kindling’ phenomenon

Alcohol Withdrawal Assessment Instruments

 A number of validated quantification instruments have

been developed for monitoring alcohol withdrawal

 No single instrument superior to another

 Quantification key to preventing access morbidity &

mortality

 Can assist clinicians to assess severity of withdrawal &

anticipate & prevent or mitigate serious complications

 Avoiding over‐ & under‐treatment of alcohol withdrawal

syndrome

 Treatment regimen can be modified according to ongoing

assessment

Alcohol Withdrawal Scales

CIWA‐Ar AWS

 Well‐documented reliability,

reproducibility & validity based

• n comparison to ratings by

expert clinicians

 Scores: 0‐7 for each of 10 items  Max score = 67  Scores < 8‐10 indicate minimal

to mild withdrawal

 Scores 8‐15 indicate moderate

Wy

 Scores 15 indicate severe Wy

(RR 3.7 for severe Wy)

 Modified version (Gold Coast

Hospital/ RBH)

 Scores: 0‐4 for each of 7 items  Max score = 28  Very severe Wy score: 15+

The Right Detox Environment

Well lit Quiet Supportive trained staff

 (Hospital staff do a great job but in many cases a

detox from alcohol in a hospital is not the ideal environment)

Sedative Regimes



Four general approaches to sedative medication

1.

Loading to sedation & stopping

2.

Loading 20mg X 3 or 4 q2H, supplemented by additional medication as per AWS score

3.

Fixed regime with tapering doses over 4‐6 days

4.

Symptom triggered dosing ‐ titrating to clinical signs on PRN basis

Alcohol Withdrawal Management

Start AWS with observations q2H during first 12‐24

hrs if AWS is expected to rise quickly & medicate in accordance (after seeing patient)

Otherwise if:

AWS Score Obs. Diazepam 1‐4 q4H Nil 5‐9 q2H 10mg 10‐14 q1H 15mg 15+ q30min 20mg

Alcohol Withdrawal Management

Mild Withdrawal Management

 Diazepam: 5‐10 mg PO PRN (as per AWS score)

Alternatively if some concern:

 D1: 5‐10mg TDS – QID baseline  Reduce by 10mg daily over 3‐5 days

Note: No driving while undergoing ambulatory withdrawal, without exception

Alcohol Withdrawal Management

Moderate Withdrawal

Fixed diazepam regime :

Day 1: 15 to 20 mg PO QID Day 2: 10 to 20 mg PO QID Day 3: 5 to 15 mg PO QID Day 4: 10 mg PO QID Day 5: 5 mg PO QID Day 6: 5mg BD +/‐

Alcohol Withdrawal Management

Severe Withdrawal Management



Diazepam Dose: 10‐20 mg PO q1h PRN while awake



Endpoint: until adequate sedation



Up to 120mg in first 12 hours



If history of seizures or DTs, load with diazepam 10‐ 20mg QID + PRN doses until settles

Alcohol Withdrawal Management

 After cumulative dose of diazepam 60mg, if agitation

• r hallucinations remain severe, consider

supplementing with:

 Haloperidol 2.5‐5.0mg IM/ PO, or  Respiridone 1.0mg BD, or  Olanzapine 10‐20mg

 Watching for signs of tardive dyskinesia which can render the

clinical situation particularly complex to manage

Loading Dose Therapy

Loading dose regimens (also called ‘front‐loading’) quickly administer high doses of benzodiazepines in the early stages of alcohol withdrawal and are indicated in:

 Managing patients with a history of severe withdrawal

complications (seizures, delirium)

 Managing patients presenting in severe alcohol withdrawal &/or

severe withdrawal complications (delirium, hallucinations, following an alcohol withdrawal seizure)

 A common diazepam‐loading regimen under these

circumstances is 20 mg orally every 2 hours until reaching 60–80 mg or the patient is sedated.

 Medical review should occur if the patient remains agitated after

80 mg.

 Other causes of agitation should be excluded, & further doses of

diazepam may be needed

 Specialist advice should be sought if necessary

Loading Dose Therapy

 The dose of 80 mg diazepam will have significant sedative

effects for several days, and this is generally sufficient to prevent severe withdrawal from occurring during the remainder of the withdrawal episode

 While no further doses of diazepam may be needed, it is

common for further doses of diazepam to be administered

• ver the subsequent 2 to 3 days for symptomatic relief, as

either a fixed reducing regimen (for example, 10 mg four times a day on day 2, 10 mg twice a day on day 3, 5 mg twice a day on day 4); or as required (for example, 5 to 10 mg 6 hourly as needed, based on clinical observation or alcohol withdrawal scale scores)

Alcohol Withdrawal Management

General Measures

 Thiamin 100 mg PO TDS

 100mg IM for 2‐3 days if poor diet or if risk of Wernicke’s

encephalopathy

 Multivitamin i daily  Treat low magnesium, potassium, phosphate or Vit K  Symptomatic medications for nausea, vomiting and

diarrhoea

Never Prescribe Benzodiazepines for Alcohol Dependence

 There is no evidence to support prescribing of

benzodiazepine medication for alcohol dependence,

• nly in a short burst for alcohol withdrawal

management

 Providing a patient with a bottle of 50 tablets of

diazepam to take‐home is not evidence‐based treatment

 This clinical action is highly likely to contribute to the

establishment of a second problem i.e. a benzodiazepine dependence

Alcohol Dependence

 Remember: a chronic relapsing & remitting

disorder

 Drinking goal setting is important  Motivational interviewing can be a useful clinical

tool

Brief Interventions

5‐Minute Brief Intervention

 Brief advice presented in non‐judgemental way

about:

 How to cut down

 Behavioural control

 counting drinks  reducing salty food intake  low alcohol drinks

 Setting personal drinking limits  Identifying high risk situations for heavy drinking

 Addressing social & environmental factors  Cognitive restructuring approaches

 Follow up

Brief Intervention

 Screening (AUDIT)  Personalised feedback based on screening including:

 Risk level & potential harms & linked to patient’s own

medical harms

 Information on standard drinks & low risk drinking  Provision of self‐help materials

Alcohol Intervention

 More comprehensive intervention is required if

AUDIT > 15 or if there are physical or psychological co‐morbidities

 Treatment goal: advise ≥ 3 months abstinence if

not indefinitely

 If that seems too tough, start with goal of 6 weeks

abstinence then review & repeat blood tests to provide positive reinforcement on health improvement

Alcohol Relapse Prevention Medications

Relapse Prevention Medications

 Modestly effective in reducing relapse, delayed return

to drinking & reduced drinking days

 Well tolerated usually

Relapse Prevention Medications*

Acamprosate (Campral)

 Modification of excitatory (Glycine) & inhibitory

(GABA) neurotransmitters diminishing craving

 Start soon after withdrawal

 333mg ii TDS  18% vs 7% abstinent after 12 mths  Compliance with TDS dosing regimen is problematic –

uncertain how much leeway might there be

 Prescribed in conjunction with counselling

Relapse Prevention Medications*

Naltrexone (Revia)

Long acting mu‐opioid receptor blocking agent Blocks endogenous opioids that are part of reward

system activated by alcohol

Reduces consumption in some & abstinence in others

• Dose: 50mg daily

Prescribed in conjunction with counselling

Relapse Prevention Medications*

Disulfiram (Antabuse)

 Blocks action of aldehyde dehydrogenase

 Accumulation of acetaldehyde

 Drinking leads to:

 Nausea, vomiting, flushing, headache, palpitations

 Dose: 200mg+ daily  Risks: hepatotoxicity, psychosis  Indications: binge drinking (?)

THANKS