Addictions 2015 Flashcards
- Alcohol Addiction History
Although you could proceed straight into taking a formal alcohol history, you are more likely to obtain an honest and accurate picture if you spend a little time developing rapport.
An open question such as ‘Please tell me more about yourself?’ is likely to help convey patient’s agenda within their personal context.
Patients with substance use problems, including alcohol, often feel a sense of shame and embarrassment when asked to discuss their consumption.
Providing permission (eg ‘It’s okay to tell me how this is affecting you’) and keeping the line of questioning open (‘Please tell me more about your drinking and why you feel it’s a problem’) can assist in breaking down this stigma in patients with substance use problems such as alcohol.
After you develop some rapport, it is important to explore specific aspects of their drinking, if they have not already disclosed this information to you.
- quantity,
- frequency,
- duration and
- pattern of drinking, as well as
- the type of alcoholic beverages consumed, are all important initial aspects to ask her about.
- at the context of drinking
- when,
- where and
- why,
- any problems they have encountered as a result of drinking
- physical,
- psychological
- and/or social), and
- features of tolerance or withdrawal they have experienced.
- You may wish to use the Alcohol Use Disorders Identification Test (AUDIT), which identifies dependent and at-risk drinkers in primary care settings, as part of your assessment.
Other substance use
- illicit and licit substances, which may include prescription drugs
- any history of mental health comorbidities – depression, anxiety, psychosis, suicide risk
- social circumstances – relationships, violence, housing, financial, legal, occupational aspects.
- assessing motivation – both her motivation for presenting to you and her motivation for change – is vital.
- As with all behavioural change interventions, an assessment of a patient’s motivation to make any suggested changes is important. Understanding motivational state will permit more targeted and effective treatment planning
- Alcohol Addiction - Examination
While alcohol can potentially affect almost every body system, and practitioners need to be systematic in physically assessing patients, specific attention should focus on:
- nutrition assessment
- neurological function
- endocrine system
- gastrointestinal system
- cardiovascular system
- mental state.
- Alcohol Use Disorder criteria
Alcohol dependence creates a cluster of physiological, behavioural and cognitive phenomena in which alcohol use takes on a much higher priority for a given individual than other behaviours that once had greater value.
The International classification of diseases, 10th edition (ICD-10) and Diagnostic and statistical manual of mental disorders, 5th edition (DSM-5) have similar criteria for assessing alcohol dependence. Either set of criteria would be appropriate to assess dependence
- Alcohol withdrawal symptoms
Symptoms of alcohol withdrawal usually commence 24 hours after the last drink; the type and severity of symptoms varies between patients and with their history of alcohol intake.
Symptoms can range from
- mild (eg anxiety, agitation, tremor, nausea, tachycardia, hypertension, disturbed sleep, raised temperature) to
- more severe (eg extreme agitation, dehydration and electrolyte disturbances, disorientation, confusion, paranoia, hallucinations, delirium tremens, seizures).
The history of current drinking patterns, past withdrawal experience(s), concomitant substance use, and medical or psychiatric comorbidities increase the risk of more severe withdrawal syndromes.
If patient wishes to cease alcohol altogether, they should be advised to undergo a detoxification program to minimise the severity of any potential alcohol withdrawal syndrome.
They are at higher risk of a more severe withdrawal with a history of morning cravings and anxiety, which are relieved by drinking. Withdrawal programs can occur in outpatient, community residential or inpatient hospital settings.
- Alcohol Withdrawal as outpatient
An outpatient alcohol withdrawal setting would be appropriate for a patient who:
- drinks <30 units of alcohol a day
- has no past history of severe withdrawal complications (eg seizures, delirium, hallucinations) or significant medical or psychiatric comorbidities (Glenda does not have any of this significant past history)
- has a safe, alcohol-free environment (eg family members house, if all the family members agree to this)
- has reliable ‘lay people’ who can regularly monitor (at least daily during the first three or four days) and support the patient
- has regular monitoring by a suitably skilled health professional
- a general practitioner [GP],
- alcohol and drug worker, nurse), who is available for daily review (face-to-face, telephone) for first three or four days.
- Depending on the location of the general practice, the GP may have allied health support, or may be in a position to provide this monitoring themselves
- has close supervision of medication (eg daily supplies) – benzodiazepines, if used to assist with cessation, can be withheld if the patient resumes alcohol use
- Alcohol Withdrawal treatment program
Alcohol withdrawal treatment should include:
- supportive counselling (eg withdrawal education, dealing with cravings, sleep advice) – patients are often very anxious about entering a detox program, and supportive education can help them and their carers to know what to expect and how to deal with common concerns
- assessment and management of diet, nutrition and hydration – alcohol-dependent patients have often neglected their diet, and addressing this is a vital component of medical care during detox. In addition, some patients can encounter more severe electrolyte disturbances, which can lead to further complications
- thiamine supplementation – used to reduce the risk of Wernicke- Korsakoff syndrome. The suggested dosing is 300 mg daily for several weeks, with the initial few days via parental route
- diazepam – used for symptomatic treatment of withdrawal symptoms and to minimise the risk of withdrawal complications. A suggested regime is 20 mg of diazepam orally, two-hourly until symptoms subside. A cumulative dose of 60 mg daily is usually adequate
- a post-withdrawal rehabilitation plan.
- Post alcohol withdrawal interventions- pharmacological
Post-withdrawal interventions include both pharmacological and non- pharmacological (psychosocial) approaches.
Pharmacological approaches
There is good evidence of improved treatment outcomes (maintaining abstinence and reduced rates of relapse) with oral naltrexone and/or acamprosate (Campral 333mg)medications. Both of these medications are on the Pharmaceutical Benefits Scheme (PBS) for the treatment of alcohol dependence.
Naltrexone is appropriate provided patient is not on opioids (as naltrexone is an opioid receptor antagonist) or have severe liver disease, as it is metabolised by the liver. Naltrexone should be taken as a 50 mg daily dose.
Acamprosate is excreted through the kidneys and would not be suitable if they had renal impairment. The dosing is 666 mg orally, three times daily for patients ≥60 kg, or 666 mg orally, in the morning, 333 mg at midday and 333 mg at night for patients <60 kg, and should be commenced one week after abstinence, if it is achieved.
There is little evidence of sustained benefit for the use of the older medication, disulfiram (antabuse), which acts as a deterrent to drinking because of the unpleasant effects when co-administered with alcohol. It has poor patient adherence and potentially harmful, life-threatening effects,8 and is therefore not recommended as the first-line relapse prevention treatment. Other agents have shown promise for the prevention of post-withdrawal relapse but are not yet recommended in the primary care setting until further research has been undertaken.
- Post alcohol withdrawal interventions- non- pharmacological
Non-pharmacological approaches
Psychosocial interventions and support are vital in post-withdrawal treatment planning.
Patients often have a number of predisposing factors that lead to their drinking. These factors need to be addressed to maximise the chance of sustained abstinence.
GPs should discuss potential referrals to services such as drug and alcohol counselling, self-help peer groups and psychologists, depending on the patient’s needs and preferences.
The family should also be offered support.
- GPs are ideally placed to identify the family’s needs and coordinate assistance through counselling services, peer support groups or organisations such as Family Drug Help (http://sharc.org.au/program/family-drug-help) and Family Drug Support Australia (www.fds.org.au).
- Long term management Alcohol dependence
The chronic nature of alcohol dependence necessitates a long-term approach. GPs are ideally placed to coordinate and deliver this care. In developing a relationship with Glenda through her initial alcohol management, you are well placed and ideally situated to help Glenda begin addressing her overall health needs.
Her hypertension, potential liver disease and mental health are obvious places to start clinically assessing and managing. This may involve referral, depending on the problems found and the resources you have available to you. Social issues (eg her relationship with her sister’s family, housing, relationship issues and employment) are also areas where her GP can provide guidance and help or referral to appropriate services.
Finally, if Glenda relapses to problematic alcohol consumption, it is important not to despair or give up. There are a number of areas where GPs can make a big difference to persistent or relapsing drinkers:
- continuing to provide encouragement to stop drinking and providing feedback on the ongoing problems caused by alcohol
- harm minimisation approaches, which can include reviewing interactions of prescribed medications with alcohol, ensuring adequate nutritional support, and focusing upon falls and accident prevention
- continuing to address other medical issues or barriers to maintaining abstinence (eg persisting or new psychiatric, medical, social problems)
- enlisting family or friends to help, and supporting them throughout this process
- ensuring we also meet our medico-legal ethical obligations (eg fitness to drive, potential children safety issues, safety within the workplace etc).
- Concentration and low motivation issues
There are many possible causes of concentration and motivation difficulties, some of which may coexist. These include:
- mental health concerns such as depression, post-traumatic stress disorder, attention deficit hyperactivity disorder
- sleep problems (sleep-onset problems and/or sleep maintenance problems) and disorders that fragment sleep (eg insomnia, sleep apnoea, periodic limb movements and nightmares)
- physical neurological disorders such as tumour, head injury, dementia
- substance misuse problems such as alcohol, cannabis, sedative use and/or amphetamine-type stimulant use
- prescribed medications (eg some antidepressants).
- Assessment of change in concentration/motivation
Initially, you could assess James for anxiety and/or depression.
- Anxiety and depression are often comorbid with a range of cognitive impairments and it is important to identify and understand all the potential contributors to the presenting symptoms.
The suggestion of mental health/mood problems should not stop
you from seeking further information about a possible substance use disorder.
- Treating substance use disorders can prevent the later onset of clinical depression and anxiety disorders in young people.
If there is evidence of significant clinical depression or anxiety, these should be treated at the same time as a substance use disorder.
- Depression and anxiety can often co-exist with substance use disorder, particularly in young people.
You could also assess for neurological disorders, although they may not have reported any head injury or physical symptoms that might indicate this.
You could use a mini mental status exam and the 6 Cognitive Impairment Test (6CIT) to clarify the nature of his current difficulties.
- History substance abuse
The assessment of a possible substance use disorder involves
- taking a detailed history and
- performing a thorough examination to
- identify any co-existing medical or psychiatric illness, as well as
- other possible contributors (eg psychosocial, physical and environmental stressors, poor sleep practices, medication use, trauma).
- Evaluation may also include interviews with a family member, partner or caregiver.
A good starting point is to ask them to describe his concentration and motivation difficulties, and key activities over a 24-hour period, commencing with his waking-up time, meals during the day and general routine.
Do this for lecture/work days and his non-lecture/work days, going back at least one week. Establish patient’s relaxation and stress relief routines, as well as peer-group activities.
The next step is to discuss the nature of cannabis use
Explain the possibility that they might have a cannabis use disorder, but that more careful examination of his behaviour over the past three months will help clarify this.
Ask patient to track back and estimate the amount of cannabis he has been using on a daily basis for the past three months. The timeline follow-back can be downloaded from the NCPIC website (see Resources).
Ask patient about his age at first use and the time course of his cannabis use. Typically, people begin using small amounts of cannabis irregularly and then either stabilise at occasional use or progress to more regular use over time. It is important to convey a non-judgemental attitude when discussing cannabis use and exploring the nature of it.
Once a broad pattern of use has been identified with particular focus on the previous three months, questioning can move to a more general inquiry as to what patient considers to be the good and not so good aspects of cannabis use.
- Cannibis Use disorder
It occurs in 20% of Australians who have ever tried cannabis (approximately 33% of the population).
According to the DSM-5, for a diagnosis of cannabis use disorder, two of the following criteria must be met:
- continuing to use cannabis despite negative personal consequences
- repeatedly unable to carry out major obligations at work, school, or home due to cannabis use
- recurrent use of cannabis in physically hazardous situations
- continued use despite persistent or recurring social or interpersonal problems caused or made worse by cannabis use
- tolerance as defined by either a need for markedly increased amounts to achieve intoxication or desired effect or markedly diminished effect with continued use of the same amount
- withdrawal manifesting as characteristic syndrome, or using the substance to avoid withdrawal
- using greater amounts or using over a longer time period than intended
- persistent desire or unsuccessful efforts to cut down or control cannabis use
- spending a lot of time obtaining, using, or recovering from using cannabis
- stopping or reducing important social, occupational, or recreational activities due to cannabis use
- consistent use of cannabis despite acknowledgment of persistent or recurrent physical or psychological difficulties from using cannabis
- craving or a strong desire to use cannabis (note this is a new criterion added since the DSM-IV-TR).
A patient who meets
- two to three of the criteria is considered to have mild substance use disorder,
- four to five criteria indicates moderate, and
- six to seven indicates severe substance use.
