Substance Misuse Flashcards
Alcohol misuse Ix
Blood: FBC, LFT, B12, folate, U+E, Clotting, glucose blood alcohol level Urine drug screen Rating (AUDIT, CIWA-Ar, APQ) SADQ
Alcohol misuse needs of family/carers
Offer carers assessment
Consider guided self help for families
Resources
Consider offering family meetings
Alcohol misuse assessment
- AUDIT: alcohol use disorder ID test >15 req. comprehensive assessment
- SADQ
- CIWA-Ar (withdrawal severity)
- APQ (assess nature and extent of alcohol related problems)
Alcohol misuse Establishing goals
Abstinence is best Rx goal (but more moderate goals may be preferred)
If comorbid mental health issues dont improve after 3-4weeks of abstinence consider referral
Principles of interventions Alcohol misuse
Carry out motivational interview
?Intensive structured community based interventions
If NFA offer residential rehab for max 3m
Routinely monitor
Info: AA, SMART, Recovery, CGL
Case management/individualised care plan if at risk drop out
Interventions for harmful drinkers and mild dependence
Offer psych intervention ((C)BT) focused on alcohol related cognitions (12 sessions)
Offer behavioural couples therapy
If no response or pharm. Rx requested, offer alongside psych therapy: Acamprosate (anticraving) naltrexone
Assisted withdrawal Alcohol misuse
Pabrinex if risk of Wernicke
Expectations: Sx worst within 48hrs, takes 3-7 total
If >15u/day, or >20 AUDIT consider:
- community based assisted withdrawal (at least 2-4meetings in first week)
- Mx in specialsit alcohol services
When to consider inpatient assisted withdrawal
> 30 units/d
30 on SADQ
Hx epilepsy, delirium tremens, withdrawal related seizure
Need concurrent alcohol and benzo withdrawal
Sig psych. comorbidity or learning disability
Lower threshold in vulnerable groups
Children 10-17 (also family therapy for 3months)
Drug regimens for assisted withdrawal
Fixed dose or symptom triggered
Preferred: chlordiazepoxide, diazepam (lorazepam if hepatic impairment)
Titrate dose based on alcohol severity
Gradually reduce dose over 7-10d (longer if concurrent BZ withdrawal)
Give no more than 2d dose at once
After successful withdrawal alcohol
Consider acamprosate or naltrexone w/individualised psychological intervention
Consider disulfiram if both unacceptable
Prescribe for 6m
Careful medical assessment (inc. LFT + U+E)
PACES alcohol withdrawal
establish risks (driving, suicide)
Assess social issues
Establish goals
Explain Sx will be worst in 48hrs gone by 7d
Advise against stopping abruptly
Explain referral to D+A service and process of assisted withdrawal
Acute alcohol withdrawal
Offer BZ (loraz) or carbamazepine (alt. clomethiazole)
Offer advice on support services
DT:
- 1L: PO loraz (if persistent IV loraz/haloperidol) (Alt. chlordiazepoxide)
-IV thiamine
If seizure: fast acting BZ (loraz) to reduce likelihood of future seizures
Opiate misuse Ix
Physical exam (baseline) Urine drug screen U+E FBC (anaemia/infection) LFTs Blood borne infection (RPR, hepatitis serology, HIV test)
Opiate misuse harm reduction
Pragmatic approach involving assessing and minimising risk rather than insisting on abstinence
Provide information on safe use
Needle exchange
Vaccination for sex workers/IVDU
Opiate misuse general recommendations
Counsel on aspects of healthy lifestyle Information about self help (12 step guide) Assess family members and carers do NOT offer withdrawal tretment: -Concurrent medical problem req. urgent treatment - in police custody - Presenting in acute/emergency setting - careful w/pregnant women
Medication for opiate detoxification
Key worker supports pts
1L: methadone (PO) buprenorphine (sublingual) consider lofexidine (a2 agonist) if others unacceptable, or mild dependence or keen for short detox
Dosing regime determined by pt. and healthcare factors
Duration:
-inpt: up to 4wks
- community: up to 12w
W/D Sx: clonidine, lofexidine
Sx: anti-diarrhoeal, anti emetic, painkiller
inpt opiate detox
only for very severe, w/physical comorbidity
basically unsafe for community
Ultra-rapid, rapid, and accelerated detox (opiate)
W/d precipitated by using high dose of opioid antagonists (naltrexone/naloxone)
Ultrarapid: 24hrs under GA or heavy sedation (should NOT be offered)
Rapid detox: 1-5d w/moderate sedation (consider if requested)
Accelerated detox: no sedation
FU for opiate detox
Refer to D+A service
at least 6m
Offer talking therapy (CBT) to prevent relapse and address underlying mental health issues
Appoint key worker
Consider contingency management after completion of detox:
- incentives for negative drug test
- screening could be 3/wk early and then reduce
- urinalysis preferred method
PACES Counselling of opiate detoxification
Get tests/vax for blood borne infections Sx of w/d: restless, sweaty, abdo cramps, N+V Timescale: peaks within 2-3d should improve by week Detox reigme and drugs Sx treatments for nausea, diarrhoea Psychological therapies key worker support groups
Benzodiazepine misuse
BZ should only be used for 2-4wk
Risks:
Short term: drowsiness, reduced concentration
Long term: cognitive impairment, worsening anxiety and depression
Address underlying problems
Clinical features of BZ w/d
Insomnia Irritability Anxiety Tremor Loss of appetite Tinnitus Sweating Seizures Perception disturbance
How to w/d from benzos
W/d in steps of about 1/8 of daily dose every 2w
Consider switching patients to eqiv. dose of diazepam (oxazepam if liver failure)
Duration: 3m-1y+
Do NOT drive if drowsy
Psych therapy for BZ
Offer CBT (underlying issues, advise about sleep hygiene)
PACES counselling in BZ use
harmful effects (long term worsening of psych sx)
BZ can be reduced v gradually, wrt sx pt. reports
Explain role of CBT
Advise against driving if drowsy
