Dr Noel Plumley Addiction Medicine Specialist

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1 Dr Noel Plumley Addiction Medicine Specialist

2 Treatment Modalities Detoxification Relapse Prevention Harm Reduction

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4 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

5 Substances of interest ALCOHOL OPIOIDS AMPHETAMINES CANNABIS BENZODIAZEPINES NICOTINE

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7 Substances of Interest ALCOHOL OPIOIDS AMPHETAMINES CANNABIS BENZODIAZEPINES NICOTINE

8 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

9 What is a standard drink? NB: Home or restaurant poured drinks are variable but are typically 2-3 standard drinks

10 Non-standard drinks

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13 Non-standard drinks Check rate of purchase of bottle/flagon Assess by packaged units (e.g. number of bottles of wine or spirit purchased per week) Get patient to pour what thy think is a standard drink. You may get a surprise!

14 Types of drinkers (adults) 5-6% 15% High risk/dependent At risk 65% Low risk 15% Non-drinker Teesson, 2000 ANZ J Psych, 34 (NSMHWB)

15 Picking up on the signals Lesson: If a patient presents to doctor with alcohol on breath, they have an alcohol problem unless & until proven otherwise 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 & offer help

16 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

17 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

18 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 ( eyeopener )? 2 positives suggests problem Limited clinical utility for early intervention horse has bolted May be helpful in others

19 AUDIT Qs 1 3: Hazardous consumption Qs 4 6: Dependence symptoms Q 7 10: Harmful drinking

20 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

21 Single Question Screening When time is limited in a clinical setting: 1. ASK: In the last year have you had 6or 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

22 Some definitions Hazardous use: drinking patterns that increase the risk of adverse consequences for the user or others Harmful use: already experiencing consequences to physical or mental health from drinking Could also include social consequences Babor et al, 2001, WHO

23 Some 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

24 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

25 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.

26 Why the definitions are important Dependent drinkers usually need to stop drinking and may experience a withdrawal syndrome, esp. on awakening Hazardous or harmful drinkers can usually cut down

27 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

28 Chronic Complications 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

29 Chronic complications 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

30 Early symptoms and signs of chronic alcohol problems Hypertension Insomnia Indigestion/diarrhoea Anxiety Depression Sick days

31 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

32 Why does alcohol cause organ damage? 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

33 Alcohol Laboratory Markers Gamma Glutamyl Transferase GGT ALT/AST Mean Red Cell Volume MCV Platelets Carbohydrate Deficient Transferrin CDT

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35 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 hr after last drink Usually lasts 5 7 days DTs more protracted (up to 14 days+)

36 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

37 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

38 Progress of the Alcohol Withdrawal Syndrome

39 Assess Alcohol Consumption 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

40 Assessment 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

41 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

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46 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

47 Alcohol Withdrawal Scales CIWA Ar Well documented reliability, reproducibility & validity based on 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) AWS Modified version (Gold Coast Hospital/ RBH) Scores: 0 4 for each of 7 items Max score = 28 Very severe Wy score: 15+

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50 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)

51 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

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53 Alcohol Withdrawal Management Start AWS with observations q2h during first 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 q1h 15mg 15+ q30min 20mg

54 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

55 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 +/

56 Alcohol Withdrawal Management Severe Withdrawal Management Diazepam Dose: 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

57 Alcohol Withdrawal Management After cumulative dose of diazepam 60mg, if agitation or hallucinations remain severe, consider supplementing with: Haloperidol mg 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

58 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 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

59 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 over 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)

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63 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

64 Never Prescribe Benzodiazepines for Alcohol Dependence There is no evidence to support prescribing of benzodiazepine medication for alcohol dependence, only 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

65 Alcohol Dependence Remember: a chronic relapsing & remitting disorder Drinking goal setting is important Motivational interviewing can be a useful clinical tool

66 Brief Interventions

67 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

68 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

69 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

70 Alcohol Relapse Prevention Medications

71 Relapse Prevention Medications Modestly effective in reducing relapse, delayed return to drinking & reduced drinking days Well tolerated usually

72 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

73 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

74 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 (?)

75 THANKS

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