15_Semple_Chap15.indd 548 12/7/2012 3:47:56 PM ALCOHOL AS A DRUG 549 Risk factors Heavy drinking is more common in men, in lower socio- economic groups, in thos e with lower educational levels, and in the young. Some professions are also associated wit h heavy drinking and drink-related harm. These include drinks industry workers (easy availa bility and effect of heavy drinkers seeking out jobs here); traveling salesmen (boredom, pe riods away from home, acceptance of drinking on the job); doctors (stress, freedom from dir ect supervision, reluctance to seek help with incipient problems). Genetics First-degree re latives of alcoholics have double the risk of alcohol problems themselves. Signi \201 cant ly higher rates in identical compared with fraternal twins (although not 100% concordance). Children of alcoholics have increased risk of development of alcohol problems themselves e ven when adopted into families without alcohol problems. A metabolically relatively inactiv e form of ALDH is common in Southeast Asian people, leading to accumulation of acetaldehyde and an unpleasant \200\230 \202 ushing \200\231 reaction in affected individuals who tak e alcohol. This may account for the signi \201 cantly lower rate of alcohol problems found in affected individuals. No causative genes for alcoholism have been identi \201 ed and i t is expected that it will show polygenic inheritance. Problem drinkers contain a signi \201 cant subgroup of individuals with dissocial personality traits which predisposes to al coholism, and is itself heritable. Medical complications Acute toxicity occurs at levels ov er 300mg% (see b p. 566), with clouding of consciousness and coma, risk of aspiration, hypo glycaemia, and acute renal failure. Associated with a wide range of chronic medical problem s (b p. 574). Psychiatric complications Harmful use and dependent use (b p. 566) distinguis hed by the presence of withdrawals on abstinence; withdrawals may be complicated by seizure s and development of an acute confusional state \200\224delirium tremens (b p. 558); acute alcohol-induced amnesia; alcoholic hallucinosis (b p. 568); alcohol-induced delusional diso rder (b p. 568); Wernicke \200\223Korsakoff syndrome (b p. 572); pathological jealousy (b p . 569); alcohol-related cognitive impairment and alcoholic dementia (b p. 568); alcohol mis use is also associated with development of, or exacerbation of, anxiety/depressive symptoms and with deliberate self-harm and suicidal behavior. Interventions Advice and \200\230bri ef interventions \200\231 regarding safer drinking patterns in those with \200\230at risk \200\231 or harmful use (b p. 566); strategies towards encouraging and maintaining abstinen ce in those with dependency and those with established medical or psychiatric damage; medic ally managed detoxi \201 cation (b p. 560); psychological and pharmacological support of a bstinence or changed drinking pattern (b pp. 562 \200\2235). 15_Semple_Chap15.indd 549 12/7/2012 3:47:57 PM CHAPTER 15 Substance misuse 550 Screening for alcohol problems Diseases related to alcohol abuse are common, signi \201 ca nt, and amenable to improvement by early detection and intervention. Screening is there- fo re indicated. There are low rates of detection in primary care and hos- pital settings, whi ch may be improved by increased vigilance, increased awareness of alcohol problems, awarene ss of routes of referral, asking routine alcohol-screening questions (e.g. CAGE \200\224see Box 15.1), paying special attention to at-risk groups. Many patients give reasonably accur ate drinking histories if asked, although some may underestimate consump- tion. A combinati on of clinical history, screening measure, and a biomarker is the optimal approach to detec tion. Disorders suggesting underlying alcohol abuse Hepatitis; cryptogenic (i.e. medically unexplained) cirrhosis; seizures \200\224particularly late onset; gastritis; anemia; unexpl ained raised MCV or deranged LFTs; cardiomyopathy; accidents, particularly repeated and poo rly explained; TB; head injury; hypertension persisting despite apparently adequate treatme nt; treatment resistance in other psychiatric conditions; impotence in men. Breath testing Blood alcohol concentration (BAC) measures recent alcohol consumption, in mg alcohol per 10 0mL blood (mg%). Correlates well with breath alcohol measured by breathalyzer (see Table 15 .1). Useful in assessing recent drinking (e.g. in supervised detox regimes) and as an objec tive measure of intoxication (e.g. in A&E). Discrepancy between high BAC and lack of appare nt intoxication suggests tolerance. This measurement is dependent on adequate technique, an d reasonable co-operation from the patient. Blood tests Elevated red cell mean corpuscular volume (MCV), gamma glutamyl transferase (G-GT), and carbohydrate-de \201 cient transferri n (CDT) are markers for excess alcohol consumption. They are best used to monitor consumpti on in patients at follow-up. Not sensitive/speci \201 c enough for routine screening purpo ses. \200 MCV months due to 120-day lifespan of RBC. False positive in B12 and folate de \201 ciency . Sensitivity 20 \200\22350%, speci \201 city 55 \200\223100%. Remains raised for 3 \200\223 6 G \200 GT Sensitivity 20 \200\22390%, speci \201 city 55 \200\223100%. Raised for 2 \200\2233wks. Other LFTs are less speci \201 c for alcoholic-related liver damage. False positive in li ver diseases of other cause, obesity, diabetes, smoking, and medication (e.g. anticonvulsan ts), and may remain raised in chronic alcoholic liver disease despite abstinence. CDT Sensi tivity 70%, speci \201 city 95%. Increased levels in response to heavy drinking (7 \200 \22310 days), 2 \200\2233wks to return to normal, can be used to monitor relapse. More expe nsive than G-GT and not available in all areas. Urinary tests Urinary ethyl glucoronide (an alcohol metabolite) has been proposed as a meas ure of alcohol intake, being sensitive to ingestion of 1 or 2 drinks, remaining elevated fo r several days. It has still to be used routinely, though has been used in forensic setting s. 15_Semple_Chap15.indd 550 12/7/2012 3:47:57 PM SCREENING FOR ALCOHOL PROBLEMS 551 Hair testing Testing of hair for ethyl glucoronide or fatty acid ethyl esters has been prop osed as a method for detecting alcohol use over prior months, though requires further resea rch and validation. Box 15.1 CAGE questionnaire A brief screening questionnaire for identi \201 cation of at-risk drinking: C: Have you ev er felt you should Cut back on your drinking? A: Has anyone ever Annoyed you by criticizing your drinking? G: Have you ever felt Guilty about your drinking? E: Have you ever had a dr ink early in the morning as an Eye-opener? More than two positive responses suggests possib le at-risk drinking and should prompt further assessment. Note: the \200\230Cage +2 \200 \231 adds two additional questions: 1. 2. What is the most alcohol you have drunk in a single day? What is the most alcohol you have drunk in a single week? Table 15.1 Breath and blood alcohol levels Breath alcohol reading (mcg%) BAC (mg%) 0.35 80 0.52 120 0.70 160 0.87 200 1.05 240 1.40 320 1.75 400 A breathalyzer allows an objective measurement of the breath alcohol and hence an approxima tion of the BAC. Breath alcohol reading should form part of the routine assessment of a pat ient presenting with alcohol problems and of patients in follow-up (e.g. supervised detox), rather than being prompted by suspicion of inaccuracy of oral report. 15_Semple_Chap15.indd 551 12/7/2012 3:47:57 PM CHAPTER 15 Substance misuse 552 Assessment of the patient with alcohol problems Patients with a primary alcohol problem, or where it is thought that alco- hol consumption is a contributory factor in their presentat ion, should have a more detailed assessment of their alcohol use, in addition to standard p sychiatric history and MSE. Lifetime pattern of alcohol consumption Age at \201 rst alcoh olic drink. Age when began to drink regularly. Age when \201 rst drinking most weekends. Age when \201 rst drinking most days. When did they \201 rst begin to drink more than t heir peers? When (if ever) did they \201 rst feel they had an alcohol problem? Pattern of drinking throughout life until present \200\224 describe periods of abstinence and more he avy drinking and the reasons for these (including environmental/psychosocial stressors). Cu rrent alcohol consumption Describe a current day \200\231s drinking. When is the \201 rst drink taken? What types of drink are taken and in what setting? What is the total number a nd volume of drinks taken in a day? Some patients \201 nd it hard to describe a typical d ay or easy to over- rationalize recent heavy consumption. Ask them to describe the previous day \200\231s drinking, then the day before that, etc., until a pattern emerges. Describe a typical and a \200\230heavy \200\231 day \200\231s drinking. Signs of dependence Do they experience withdrawals in the morning or when unable to obtain alcohol? Have they ever dru nk more alcohol as way of relieving withdrawals? Are they having to drink more to get the s ame intoxicating effect? Do they no longer get \200\230drunk \200\231 at all? Do they \201 nd it dif \201 cult to stop drinking once started? Have they tried and failed to give up, and if so why? Do they have episodes of \200\230lost \200\231 memory/ \200\230blackou ts \200\231? Physical/mental health Have they been told of any physical health problems due to drinking? Have they previously been told to stop drinking by a doctor? Any previous or current psychiatric diagnoses? Problems related to alcohol Have they missed days at work, o r had warnings about poor performance, or lost a job as a result of alcohol? Are there rela tionship dif \201 culties or a relationship breakdown due to drinking? Are there \201 na ncial problems? Have they been in trouble with the police or do they have outstanding charg es against them? Previous treatment attempts Describe the nature and type of previous treat ments. Describe the subsequent return to drinking. Describe any periods of abstinence since the development of the drinking problem. How were they maintained and what ended them? Fam ily history Drinking problems in parents and extended family. Quality of relationships in p ast and present. Childhood environment. Attitude to referral Why have they attended the app ointment today? Do they feel they have an alcohol problem and if so will they accept help f or it? What sort of help do they want and are there types of treatment 15_Semple_Chap15.indd 552 12/7/2012 3:47:57 PM ASSESSMENT OF THE PATIENT WITH ALCOHOL PROBLEMS 553 they will not accept? What stage of change are they at (pre-contemplative, contemplative, d ecision, action)? Patient goals What (if anything) do they want to change about their drink ing? What pattern of drinking do they aspire to? Physical examination Note general conditio n; evidence of withdrawals including tremor in hands or protruded tongue; degree of facial capilliarization; stigmata of liver disease (palpable liver edge, jaundice, spider naevi, a scites, palmar erythema); evidence of peripheral neuropathy; ataxia of gait; breath alcohol reading. Blood testing FBC, LFTs, other blood tests as indicated on history/ examination. Cognitive testing Although not generally indicated until 4wks of abstinence, it is helpful to get a feel for the patient \200\231s level of cognition, especially if there is a sugges tion they may be experiencing delirium, or have signi \201 cant alcohol-related brain dama ge. 15_Semple_Chap15.indd 553 12/7/2012 3:47:57 PM CHAPTER 15 Substance misuse 554 Giving drinking advice There are a variety of situations where the doctor will be called on to give \200\230safe drinking \200\231 advice: individuals whose histories reveal evolvin g risky drinking patterns; patients with comorbid psychiatric illness; and individu- als wi th alcohol problems who are attempting controlled drinking rather than abstinence. There is a wide variety of types of alcoholic drink, each of a different \200\230strength \200\231, (i.e. percentage alcohol by volume; see Table 15.2). It is the amount of alcohol taken, rather than the type of drink, which contributes to physical/mental health effects \200\224avoiding spirits or other drinks per- ceived as \200\230strong \200\231 will not p rotect from health risks if the absolute amount of alcohol is above safe limits. Sensible d rinking Men should drink no more than 21 and women no more than 14 units/wk of alcohol. The re should be at least two non- drinking days per week. The amounts should be spread over se veral days, not drunk all at once. Amounts should not be \200\230saved up \200\231 from a light week and drunk on top of the following week \200\231s allowance. The amounts quoted a re not \200\230safe \200\231 amounts, but represent levels of drinking not associated with signi \201 cant risks to health. In some situations (e.g. driving, operating machinery) t he \200\230safe amount \200\231 is zero. Some individuals (e.g. previously alcohol-depende nt, chronic medical conditions, pregnant) should not drink at all. Brief interventions for hazardous and harmful drinking Low intensity, short interventions, based predominantly at primary care level, to reduce hazardous drinking. Techniques include presenting patients with screening results, identifying risks, giving medical advice, asse ssing the patient \200\231s goals/commitment and working collaboratively to support the pat ient. Techniques of controlled drinking Patients who are seeking advice about avoiding pote ntial alcohol problems and those individuals who are seeking to change from \200\230at-ris k \200\231 or harmful drinking patterns to controlled drinking patterns may \201 nd a sel ection of the following strategies helpful: \200 \200 \200 \200 \200 \200 \200 \200 Set a weekly and daily alcohol limit and keep to it. Do not drink alone. Do not drink with individuals who drink heavily themselves. Pace drinking, matching the consumption of a ligh t or slow drinker. Don \200\231t buy rounds. Alternate soft and alcoholic drinks. Drink wit h a meal. Rehearse what to say if offered a drink that you don \200\231t want. Plan alterna tive, enjoyable non-drinking activities to replace drinking periods (e.g. cinema, sports). 15_Semple_Chap15.indd 554 12/7/2012 3:47:57 PM GIVING DRINKING ADVICE 555 Table 15.2 Amounts of alcohol in common drinks The amount of alcohol in drinks is measured in units. One unit contains 78 grams of alcohol . In alcoholic drinks where the percentage of alco- hol by volume is given, the number of u nits = volume in L x % alcohol. Numbers of units in common drinks are given below. In calcu lating numbers of units in an alcohol history, remember that home measures of drinks are us ually more generous than those in pubs. Drink Alcohol % by volume Measure Alcohol units Beer and stout 4.0 Pint 2.0 Continental lager 5.0 440ml can 2.2 Strong lager 9.0 440ml can 4.0 Normal cider 4.5 Pint 1L 2.5 4.5 Strong cider 8.4 1L 8.4 Wine 9 \200\22314 125ml glass 750ml bottle 1.5 6.8 \200\22310.5 Gin/vodka/ rum 37.5 25ml measure 700ml bottle 1 26.3 15_Semple_Chap15.indd 555 12/7/2012 3:47:57 PM CHAPTER 15 Substance misuse 556 Planning treatment in alcohol misuse Patients presenting with alcohol problems often displa y marked ambiva- lence about whether there is even a problem, let alone about the need for change. This re \202 ects both the perceived positive as well as negative roles alcohol pl ays in their lives and the memory of previous failure or dif \201 culties in attempting ch ange. The aim in counseling such patients is to guide them in making their own decision tow ards change, or if change is not likely or possible now, to guide them towards harm reducti on and considering the possibility of future change. Motivational interviewing This is a te chnique aimed at enabling a patient to move through the stages of change (b p. 544) to the point where action can be contemplated. It is based on the principle that: \200\230people believe what they hear themselves say \200\231. The interviewer aims to aid the patient in explaining why they should change their behavior and how this will be achieved. \200 Therapist does not take a directive or prescriptive role but expresses interest and concern for the patient \200\231s problems and explores the consequences of their behavior. Uses o pen-ended questions, re \202 ective listening and summarizing with identi \201 cation of discrepancy between individual statements. Aids the assessment of the pros and cons of curr ent behavior, avoiding confrontation or direct challenge. Emphasizes patient \200\231s own perceptions of degree of risk rather than telling them about risks which they may not belie ve. Encourages personal responsibility and patient \200\231s choice of treatment options. Planning interventions The initial assessment interview forms the beginning of intervention . Its aims are to gather and impart information, promote the possibility of positive action , and to plan treatment. The ongoing therapeutic relationship aims to maintain purpose, mon itor progress, aid self-monitoring and self-awareness. The process of planning treatment sh ould proceed along the following lines: \200 \200 \200 \200 Make diagnosis (alcohol dependence, harmful, or at-risk use). b p. 544). Assess stage of ch ange ( Decide with patient the goal of intervention: Continue current drinking pattern In s ome patients there will be no need for change at all. In others there will be a clear histo ry of alcohol problems but the patient presents as \200\230pre-contemplative \200\231 rega rding change. In these cases give harm-reduction advice and \200\230leave the door open \200\231 to further assessment and help rather than alienating the patient. Change to safer drinking pattern Many individuals will be able to modify risky or harmful drinking pattern s given appropriate advice and help (perhaps monitored by a \200\230drinking diary \200 \231, which is later reviewed). Attempt abstinence from alcohol course is to aim to abstain from alcohol completely. For abstinence in a dependent drinker, consider the need for and setting of detox (b p. 560). In some individuals the only safe 15_Semple_Chap15.indd 556 12/7/2012 3:47:57 PM PLANNING TREATMENT IN ALCOHOL MISUSE 557 Plan support methods and follow-up (b p. 562). \200 At follow-up contact, review progress, emphasize changes made, review mental health. Antici pate and deal with relapse if it occurs. Abstinence vs. controlled drinking The decision to try for controlled drinking rather than abstinence is one for individual patient choice. The doctor should offer suitable advice. \200 Factors suggesting possibility of success of controlled drinking: previous prolonged period s of controlled drinking, alcohol misuse primarily in context of other mental disorder whic h has responded to treatment, otherwise stable lifestyle, absence of drinking problem in fa mily and friends. Factors against controlled drinking: dependent, previous failure at contr olled drinking, comorbid mental illness, comorbid drug use, established organ damage, risk of job loss/ marriage loss. previously alcohol- Relapse Alcohol misuse is a chronic illness and many patients will \200\230fall off the wa gon \200\231 several times before achieving long-standing change. The possibility of relaps e should be anticipated with the patient and appropriate strategies should be in place to d eal with it (e.g. early review). Causes of relapse: ambivalent motivation, insuf \201 cient support, novel events, over-con \201 dence, mental illness, environmental stressors. Counseling families The family of a patient with alcohol problems may contact you directly to ask for advice regarding their re lative. \200 Patient \200\231s relatives sometimes request that their relative be detained in hospital \200\230to stop them drinking \200\231. The Mental Health Acts in the UK speci \201 cally do not allow detention of patients solely for reason of drug or alcohol dependency. Aim to encourage and reward moves by the drinker to achieve change in their drinking pattern, whil e avoiding rewarding and hence reinforcing drinking, but avoiding confrontation or ultimatu ms. Sometimes continued family involvement, despite their best intentions, serves only to s upport the drinker in their chosen lifestyle. In this case the family may have to be aided to step back (AA call this \200\230disengaging with love \200\231). Prognostic factors There is 73.6-fold excess mortality cf. age-matched controls. Of 100 45- yr-old patients at 20yrs follow-up: 40% dead, 30% abstinent, 30% problem drinking. Positive factors Motivated to change; supportive family or relationship; in employment; treatable c omorbid illness (e.g. anxiety disorder, social phobia); accepting of appropriate treatment goal; AA involvement. Negative factors Ambivalent about change; unstable accommodation or h omeless; drinking embedded into lifestyle (e.g. limited pursuits outside alcohol, all frien ds are drinkers); repeated treatment failures; cognitive impairment. 15_Semple_Chap15.indd 557 12/7/2012 3:47:58 PM CHAPTER 15 Substance misuse 558 Alcohol withdrawal syndromes In a patient with alcohol dependence, stopping alcohol complet ely or sub- stantially reducing the usual amount causes the development of character- istic withdrawal syndromes. These syndromes should be anticipated, and prophylaxis considered in any patient: \200 \200 \200 With a history of dependence. Who has previously experienced withdrawal syndromes. Who has consumed more than 10 units of alcohol on a daily basis for the previous 10 days. Currently experiencing withdrawals. Uncomplicated alcohol withdrawal syndrome \200 \200 Occurs 4 \200\22312hrs after the last alcoholic drink. Features \200\224coarse tremor, swea ting, insomnia, tachycardia (pulse >100), nausea and vomiting, psychomotor agitation, and g eneralized anxiety. Occasionally, transitory visual, tactile, or auditory hallucinations or illusions. There may be increasing craving for alcohol both in itself and as a relief from withdrawal symptoms. Symptoms increase in severity in rough proportion to the habitual alc ohol consumption, peaking at 48hrs and lasting 2 \200\2235 days, with symptoms being more p rolonged in heavier drinkers. Alcohol withdrawal syndrome with seizures \200 In 5 \200\22315% of cases withdrawals are complicated by grand mal seizures occurring 6 \200\22348hrs after the last drink. If seizures occur only during withdrawal they do not si gnify the development of idiopathic epilepsy. Predisposing factors: previous history of wit hdrawal seizures, idiopathic epilepsy, history of head injury, hypokalaemia. Delirium tremens Acute confusional state (b p. 790) secondary to alcohol withdrawal. A medi cal emergency requiring inpatient medical care. \200 75% of episodes of withdrawal. Onset 1 \200\2237 days after the last Occurs in drink with a peak incidence at 48hrs. Risk is increased by severe dependence, com orbid infection, and pre- existing liver damage. In addition to the features of uncomplicat ed withdrawal there is: \200 \200 \200 \200 \200 Clouding of consciousness. Disorientation. Amnesia for recent events. Marked psychomotor ag itation. Visual, auditory, and tactile hallucinations (characteristically of diminutive peo ple or animals \200\224 \200\230Lilliputian \200\231 hallucinations). Marked \202 uctuati ons in severity hour by hour, usually worse at night. In severe cases: heavy sweating, fear , paranoid delusions, agitation, suggestibility, raised temperature, sudden cardiovascular collapse. \200 15_Semple_Chap15.indd 558 12/7/2012 3:47:58 PM ALCOHOL WITHDRAWAL SYNDROMES 559 Reported mortality of 5 \200\22310%. It is most risky when it develops unexpectedly and its initial manifestations are misinterpreted (e.g. in a patient not known to be alcohol-depen dent developing symptoms post-operatively). Differential diagnosis: hepatic encephalopathy, head injury, pneumonia, acute psychotic illness, acute confusional state with other primar y cause. 15_Semple_Chap15.indd 559 12/7/2012 3:47:58 PM CHAPTER 15 Substance misuse 560 Management of alcohol withdrawal Detoxi \201 cation (detox) is the medical management of w ithdrawal symp- toms in a patient with substance dependence. Alcohol detox involves: psycho logical support; medication to relieve withdrawal symptoms (usu- ally via a reducing BDZ re gime); observation for development of features of complicated withdrawal; nutritional suppl ementation; and integration with follow-up. Detox may be carried out as inpatient or, with support, in the community. The need to medically manage the complications of alcohol withdr awal can also arise in an unplanned fashion (e.g. in an alco- hol-dependent patient in poli ce custody or following emergency surgery). Most of the problems of alcohol use are related to inability to maintain abstinence, rather than to the initial problems of withdrawal. Detox procedure \200 Decide on setting. \200 Assess need for BDZ-reducing regime. \200 Consider need for other medications. \200 Provide verbal and written advice. \200 Inf orm GP of the plans. \200 Give the patient a contact in case of emergency. \200 Decide on explicit follow-up after detox. Setting Outpatient detox \200 Treatment of choice for most uncomplicated alcohol-dependent patients, with comparable comp letion rates to inpatient detoxi \201 cation and comparable percentage remaining abstinent at 6mths. Where there are doubts about compliance or concerns about drinking \200\230on t op of \200\231 the prescribed drug, the patient should be seen daily in the morning and bre athalyzed before dispensing that day \200\231s and the following morning \200\231s supply o f the drug. Indications for inpatient detox \200 \200 \200 \200 \200 \200 Past history of complicated withdrawals (seizures or delirium). Current symptoms of confusi on or delirium. Comorbid mental/physical illness, polydrug misuse, or suicide risk. Symptom s of Wernicke \200\223Korsakoff syndrome ( Severe nausea/vomiting; severe malnutrition. Lac k of stable home environment. b p. 572). Reducing regime BDZs are prescribed in alcohol withdrawal to ameliorate unpleasant with- dr awal symptoms (e.g. tremor, anxiety) and to reduce the risk of with- drawal seizures. They are prescribed in a rapidly reducing regime in order to avoid the development of secondary, iatrogenic dependence, while covering the period of maximum risk (see Table 15.3). \200 Many units prefer chlordiazepoxide to diazepam for outpatient use as it has lower abuse pot ential. Diazepam is often preferred for inpatient use as it is faster acting, allowing dose titration against effect, and can be given parenterally. Preferred in those with history o f alcohol withdrawal seizures. 15_Semple_Chap15.indd 560 12/7/2012 3:47:58 PM MANAGEMENT OF ALCOHOL WITHDRAWAL 561 Indications for prescribing a reducing regime \200 \200 \200 Clinical symptoms of withdrawal. History of alcohol dependence syndrome. Consumption is gre ater than 10 units/day over the previous 10 days. Not required if \200 \200 \200 <10 units daily. No history of withdrawals/drinking to avoid anticipated withdrawals. BAC = 0 and no withdrawal symptoms. Symptom monitoring Review patients regularly to assess withdrawals. Continuing symptoms sho uld be managed by increasing the next day \200\231s planned dosages, rather than increasing the length of the course or relying on \200\230PRN \200\231 dosage. Table 15.3 Benzodiazepine withdrawal regime Suggested outpatient reducing regime using chlo rdiazepoxide. On waking Midday Early evening At bedtime Day 1 \200\224 30mg 30mg 30mg Day 2 20mg 20mg 20mg 20mg Day 3 20mg 10mg 10mg 10mg Day 4 10mg 10mg \200\224 20mg Day 5 10mg \200\224 \200\224 10mg Other medications \200 Anticonvulsants anticonvulsants in alcohol withdrawal. Other oral drugs (e.g. phenytoin, carbamazepine) do not reach therapeutic level until after the time o f maximal risk. Antipsychotics Where hallucinations or delusions develop they can usually b e managed by temporarily increasing the BDZ dose. Addition of an antipsychotic (e.g. halope ridol 5 \200\22310mg orally up to tds) should be considered if this fails. Antipsychotics r educe seizure threshold; with suf \201 cient BDZ cover this should not be a concern. Suppl ementary vitamins of Wernicke \200\223Korsakoff syndrome or evidence of malnourishment give parenteral B vitamins (b p. 572). In other patients give a 4-wk course of 100mg thiamine, tds, in addition to multivitamins (mineral de \201 ciencies, e.g. magnesium, are commonly seen in this group, and can predispose to withdrawal seizures). Other psychotropics While m any patients withdrawing from alcohol complain of anxiety and/or depressive symptoms, many will be directly s to alcohol use/withdrawal. Do not treat with psychotropics until patient has been assessed when abstinent from alcohol. Generally speaking, do not start new psycho tropics at this time. BDZs in suf \201 cient dosage are the most effective Where there are symptoms suggestive 15_Semple_Chap15.indd 561 12/7/2012 3:47:58 PM CHAPTER 15 Substance misuse 562 Maintenance interventions in alcohol misuse 1: psychological methods In planning treatment in alcohol problems, attention should be focused not only on achieving, but also on maintai ning change. Many patients \201 nd the initial change (e.g. moving to abstinence or contr olled drinking) sur- prisingly easy, but \201 nd it dif \201 cult to maintain change in the longer term. Alcohol misuse is a chronic illness characterized by relapse and in depend - ent drinkers there is the tendency for dependent drinking patterns to recur rapidly on ab stinence. For this reason, maintenance interventions should support change, and in every pa tient, relapse should be anticipated and strategies to deal with it should be in place. Ind ividual counseling In addition to monitoring agreed change, individual counseling can addre ss the following: \200 \200 \200 \200 \200 \200 Social skills training (e.g. \200\230saying no \200\231). Problem-solving skills. Relaxati on training. Anger management. Cognitive restructuring. Relapse prevention. In selected patients there may be a role for more formal psychotherapies. Group support Var iety of group methods both within the health service and in the voluntary sector. Variable local provision. Most widespread and best known is AA (see Box 15.2). Pharmacological suppo rt (b p. 564). Residential abstinence In selected patients, time in a residential facility may offer a period of abstinence which is unachievable \200\230outside \200\231, allowing interventions in physical and mental health and a chance to plan social change to permit co ntinued abstinence on discharge. A variety of facilities exist, usually outside health care provision; some offer detoxi \201 cation, while others will only accept patients followin g detox. Most residential rehabilitation centers will utilize group therapies, and follow t he \200\23012-step \200\231 approach, advocated by Alcoholics Anonymous (b p. 563). Reside ntial rehabilitation is used in patients where home environment is unsupportive of abstinen ce and there has been failure of previous treatment options. Advice to all patients regardi ng relapse Returning to drinking is the most common outcome in patients (and some consider relapse as pathognomonic of addiction). The stages of change model (b p. 544) considers rel apse to be at the beginning of a further process of change, but with increased knowledge as to future strategies to combat relapse. A relapse can be motivated by over-con \201 dence or forgetting gains. A \200\230slip \200\231 does not mean a full-blown relapse is inevit able and all patients should have strategies to deal with relapse discussed and agreed \200\230ahead of time \200\231. 15_Semple_Chap15.indd 562 12/7/2012 3:47:58 PM MAINTENANCE IN ALCOHOL MISUSE 1: PSYCHOLOGICAL METHODS 563 Box 15.2 Alcoholics Anonymous (AA) Alcoholics Anonymous (AA) is the best known and the most widespread of the voluntary self-h elp organizations for problem drinkers. It was founded in 1935 in the USA by Bill Wilson an d Dr Bob Smith, themselves both problem drinkers. Currently there are 73 000 groups in the UK and 788 000 groups worldwide. Associated organizations are Al-Anon (for relatives of pro blem drinkers); Al-Ateen (for teenage children of problem drinkers); and Narcotics Anonymou s (NA) (for addicts of illicit drugs). AA views alcoholism as a lifelong, incurable disease whose symp- toms can be arrested by li felong abstinence. Many other groups will use a variant of the AA model \200\23012-step \200\231 program. AA is a useful and effective intervention in many problem drinkers and al l patients should be informed about AA and encouraged to consider attendance. An AA meeting will generally follow a standard routine: there will be 10 \200\22320 people in each group, only \201 rst names are used; a rotating chair- man will introduce himself with \200\230my name is X, and I am an alcoholic \200\231, then will read the AA preamble ; a number of speakers are called from the \202 oor who give an account of their stories and recovery if possible, lead- ing to general discussion; the meeting ends with a prayer a nd is followed by informal discussions and contact between new members and spon- sors who m ay offer emotional and practical support and perhaps a phone number. Open meetings are held where friends, family, and interested professionals can attend. Closed meetings are for AA members only. (See Useful resources for AA contacts in the UK and Ireland b p. 1014.) The \200\23012 steps \200\231 1. We admitted we were powerless over alcohol \200\224that our l ives had become unmanageable. 2. Came to believe that a power higher than ourselves could restore us to sanity. 3. Made a decision to turn our will and our lives over to the care of God as we understood him. 4. Made a searching and fearless moral inventory of ourselves. 5. Admitted to God, to ourse lves, and to another human being the exact nature of our wrongs. 6. Were entirely ready to have God remove these defects of character. 7. Humbly asked Him t o remove our shortcomings. 8. Made a list of the persons we had harmed, and became willing to make amends to them all. 9. Made direct amends to such people wherever possible, except when to do so would injure them or others. 10. Continued to take personal inventory, and when we were wrong promptly to admit it. 11. Sought through prayer and meditation to improve our conscious contact with God as we un derstood Him, praying only for knowl- edge of His will for us and the power to carry that o ut. 12. Having had a spiritual awakening as a result of these steps, we tried to carry this mes sage to alcoholics and to practice these principles in our affairs. 15_Semple_Chap15.indd 563 12/7/2012 3:47:58 PM CHAPTER 15 Substance misuse 564 Maintenance interventions in alcohol misuse 2: pharmacological methods Aversive drugs Disul \201 ram Action Irreversible inhibition of acetaldehyde dehydrogenase (ALDH) which conver ts alcohol to carbon dioxide and water. If alcohol is taken, there is a build-up of acetald ehyde in the bloodstream causing unpleasant symptoms of \202 ushing, headache, nausea and vomiting, and tachycardia. There is also recent evidence to suggest it may block dopamine B hydrox- ylase, increasing dopamine and decreasing noradrenaline. Indication Can act as a helpful adjunct to therapy and allow the patient \200\231s relative s/employers to regain con \201 dence in their ability to remain absti- nent (evidence for increased ef \201 cacy with supervised administration). Dose Prescribe once abstinence achieved. Starting dose: give loading dose of 800mg and then reduce over 5 days to 100 \200\223200mg daily or 200 \200\223400mg on alternate days. Side-effects Halitosis and headache. Rare reports of psychotic reactions and hepatotoxicity . Notes \200 Patients should be counseled as to the nature and purpose of the drug and the likely side-e ffects if they drink. It is no longer recommended to give an alcohol \200\230challenge \200\231 to a patient newly started on disul \201 ram. Compliance is increased if the taki ng of the drug is monitored by another person (e.g. spouse). Anti-craving drugs Acamprosate Action Believed to act through enhancing GABA transmission i n the brain. Has been found to reduce alcohol consumption in animal models of alco- hol add iction, with possible neuroprotective effects. Patients taking it report diminished alcohol craving. In RCT, cohort treated with acampro- sate showed an increased percentage remainin g abstinent and a doubling of time to \201 rst relapse. The majority of trials have been conducted with adjunctive psychosocial treatments, and therefore these should accom- pany t reatment. Indications Patients who wish to remain abstinent from alcohol. Dose Once abstinence achieved: 666mg tds. Can be started at the end of detoxi \201 cation. Side effects GI upset, pruritus, rash, altered libido. (Generally well tolerated.) 15_Semple_Chap15.indd 564 12/7/2012 3:47:59 PM MAINTENANCE IN ALCOHOL MISUSE 2: PHARMACOLOGICAL METHODS 565 Notes \200 Discontinue if patient returns to regular drinking or relapses more than once while on the drug. Has no role in assisting with controlled drinking. Has no aversive action if alcohol is taken (though can be used in conjunction with disul \201 ram). Has no addictive potenti al itself. \200 Naltrexone Action Antagonizes the effects of endogenous endorphins released by alcohol cons umption. It is believed that this diminishes both the desirable \200\230high \200\231 expe rienced on taking alcohol and the loss of control reported by most dependent drinkers. Indications In motivated subgroups of alcohol-dependent patients it appears to be effective in reducing total alcohol consumed and number of drinking days. Dose Once abstinence achieved, give 25mg od initially, maintenance 50mg od. Side effects GI upset, feeling anxious/ \200\230on edge \200\231, headache, fatigue, sleep disturbance, \202 u-like symptoms. Notes \200 \200 Does not have an aversive or dependence-producing effect. Not currently licensed in the UK for treatment of alcohol dependence. 15_Semple_Chap15.indd 565 12/7/2012 3:47:59 PM CHAPTER 15 Substance misuse 566