Alcohol and smoking

Question 1

Nicotine replacement therapy

Answer 1

Double quit rate
Attempt to cease all within 12 weeks
Combination therapy (patch plus short acting) has better efficacy

Transdermal patch

• slower release
• doesn’t provide rush/rapid absorption

Gum/inhaler/losanger/oral spray/sublingual

• rapid onset
• provides relief from cravings similar to smoking

Contraindications
-recent MI/CVA
-severe arrhythmias 
-unstable angina
risk is lower than smoking and benefits outweight risks

Question 2

Varenicline

Answer 2

MOA

• partial nicotine agonist
• doubles quit rate
• higher rate when two 12 week courses done

SE

• nausea
• cardiovascular risk
• mood disturbance, behavioural disturbance, depression and suicide
• caution in psychiatric illness
• dose reduce in kidney disease

Question 3

Bupropion

Answer 3

MOA

• norepinephrine reuptake inhibitor
• > inhibits presynaptic reuptake of dopamine and norepinephrine

SE

• seizures
• dry mouth
• nause
• insomnia
• numerous drug interactions
• > anti psychotics
• > anti depressants

Question 4

Disulfuram

Answer 4

MOA:

• Inhibits aldehyde dehydrogenase
• (disulfiram effect) flushing, headache, nausea and vomiting

SE:

• hypotension
• tachycardia
• palpitations
• sense of impending doom
• tachypnea and dyspnea
• cardiorespiratory failure
• hepatoxicity

Compliance is an issue. Good for young, fit, highly motivated patients.

Question 5

Acamprosate

Answer 5

MOA:

• incompletely understood
• structural analogue to taurine and GABA
• In nucleus accumbens, increases the activity of GABA-ergic system and decreases activity of glutamate, possibly by suppressing calcium induced calcium entry.
• Is thought to restore balance to GABA and glutamate activities, which appear disrupted in alcohol use disorder
• Not effective in treatment of acute phase of withdrawal, but reduces its chronic symptoms (anxiety, irritability, insomnia, craving)
• Increases time to first drink, prolongs abstinence and reduces number of drinking days

SE:

• dose reduce in kidney disease
• diarrhoea

need to take tablets 3x daily (6 in total)

Question 6

Naltrexone

Answer 6

MOA

• pure opioid competitive antagonist
• relatively selective for mu receptor
• reducing the reinforcing effects of alcohol consumption
• reduces relapse of heavy drinking and increases abstinence days

SE:

• GI distress (nausea, vomiting)
• headache
• rash
• syncope
• impaired cognitive
• depression, anxiety, fatigue
• transaminitis

blocks pain relief from opioid agonists

Question 7

Non pharm alcohol use disorder

Answer 7

All show modest benefit. Limited head to head trials, no clear advantage of one of others.

Brief intervention
-more useful for at-risk drinkers

Motivational interviewing
-eliciting behavioural change by helping patient explore and resolve ambivalence to change behaviour

CBT

• structured, goal-directed form of psychotherapy based on the theory that thought processes contribute to behaviour in deleterious cycle
• psychoeducation
• de-arousal techniques
• behavioural training (increasing recovery focused activities eg. mutual help group)
• cognitive training (coping skills, social skills)
• problem solving
• response inhibition (urge surfing)

Couples and family therapies

• usually non-SUD partner
• both make commitment to each other, to be abstinent and to support recovery
• decrease in triggers and increase in support for positive behaviours

Addiction counselling

• can be individual or group (most effective when combined)
• most based on twelve step program (most famous is AA)
• work towards abstinence through group sharing and support

Residential therapy

• best for high risk patients, unsuccessful initial treatment or significant environmental triggers
• substance free environment
• provided many of the above interventions while attending

Question 8

Non pharm smoking

Answer 8

5 A’s approach

Ask
-ask every patient about smoking status

Assess (readiness to change and dependence)
readiness to change
-how do you feel about your smoking?
-do you want to quit?
dependence
-how many per day? (>10)
-how quickly within waking (<30mins)
-withdrawal symptoms?

Advise
-discuss harms of smoking and benefits of cessation

Assist
not ready 
-inform that help is available when ready
-consider passive smokers
-consider barriers
unsure
-motivational interviewing
ready
-encourage/affirm
-provide pharm to dependent
-information/support (eg. QUIT referral)
action and maintence
-congratulate
-discuss relapse prevention

Arrange follow up
-within 1 week of quit attempt
successful
-congradulate
-discuss relapse prevention (awareness of triggers, coping strategies)
-continue for 5 years
attempting
-encourage/affirm
-pharm
-encourage use of supports
relapse
-learning experience
-explore reasons why
-support/extremely common