Promoting Self Care for Homeless People who are dependent on alcohol-a case study or a journey depending on your viewpoint

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1 Promoting Self Care for Homeless People who are dependent on alcohol-a case study or a journey depending on your viewpoint Pam Campbell Nurse Consultant Homeless Healthcare Team

2 What does self management mean? Coping with the condition on a daily basis Managing acute exacerbations Dealing with the psychological impact of a chronic condtion Knowing when to seek help

3 The three axes of self management = motivation, information and application

4 Alcohol Dependence Definition:- AUDIT score higher than 16 (20) SADQ score higher than 20 Low risk Increasing risk High risk Diagnosis a thorough alcohol history- know your number, alcohol conversations with a mental ready reckoner for units, patterns of drinking, time to first drink of the day, breathalysers.

5 Physical health problems associated with alcohol dependence Liver: alcoholic hepatitis, cirrhosis, liver cancer. Gastrointestinal tract: oral cavity cancer, oesophageal neoplasm, oesophageal varices, pancreatitis. Cardiovascular system: atrial fibrillation, hypertension, strokes and cardiomyopathy with heart failure. Neurological system: acute intoxication with loss of consciousness, withdrawal, seizures, subdural haemorrhage, peripheral neuropathy, Wernicke-Korsakoff syndrome and cerebellar degeneration Kindling effect of repeated detox

6 Psychosocial Problems Suicidal ideation Depression Anxiety Loss of libido Fetal alcohol syndrome Relationship problems. Violent crimes - eg, domestic violence and drink driving offences. Antisocial behaviour. But in fact alcohol use disorders like smoking are an addiction and though we seek to rationalise why the exigency is to manage and to minimise harm.

7 Alcohol Related Liver Disease (ARLD) What condition are we managing? ARLD vs Alcohol Dependence

8 What we know Christos Kouimtsidis (2014) Rushed detoxes should be avoided (NICE 2010) Repeated detoxes=worse outcome (Loeber et al, 2009) CBT interventions effective for Relapse Prevention (Mesa Grande Review, USA, 2003)

9 Potential changes Should we avoid fluctuations; try to stabilise? Should we aim for gradual reduction rather than detox? Advice not to stop abruptly Should we only detox, when we have reduced relapse risk to the minimum? Can we? HOW? WHAT? WHEN?

10 Jon 38 year old Scotsman Lost contact with family in Scotland has children but not see them for 15 years he has been in Southampton 25 year Hx of heavy alcohol use Hepatitis C positive Diagnosed with Hepatic Encephalopathy Living between the street and hostels for homeless people for past 11 years (numerous detoxes of those undertaken in the past 3 years (many in hospital) he began drinking within a day of completion Also uses heroin but threshold for this much increased when he is extremely intoxicated Currently drinking over 300 iu/week

11 Self Management- the process Jon doesn t want to stop drinking, doesn t want to die in hospital and housing options are few, feels comfortable in the hostel Motivation to self manage- avoid hospital admission -reduce heroin use -reconnect with family if only by letter Information to self manage, Liver function, GGT? Liver Fibrosis markers Alcohol consumption what % and what volume and when with whom Spirits > Strong Lagers >White Cider > Brown Cider Application :-Alcohol doses, treat as medication, quantity and timings. Negotiate a plan and write it down. Think about pinch points, pay day, daily activity, distractions. Prescribing, Thiamine, Vitamin B Co, Omeprazole, Naloxone, Zopiclone (two weeks per month) Aymes Shakes and alcohol? Review, review, review I

12 Jon s plan Eradicate vodka Initially White cider but agreed to cans as dosing more manageable (cost implication to consider) Jon drinks through the night as sleep is poor but we wished to address this with increased daily activity-fishing risky but he can swim and is supervised Short term hypnotic and Jon would try no alcohol from 12midnight through to 5.30 am and he would keep breakfast cereal as well as shakes in his room to eat prior to first alcohol Initially 8 cans 8% per day, dosing interval 2.5 hours (reduction of 12iu/day) Currently on 6 cans 8% 3-4 hourly (further reduction 8iu/day) Weekly intake in theory >300iu to 225iu/week to 168iu/week, taken 6 months There have been blips!

13 Benefits Jon feels he has wrested back some control More or less written off by hepatology when drinking over 300iu/week but they are prepared to see him and Fibrocan his liver but unlikely to be any treatment Has not presented at the emergency department for the six months the plan has been in place Accommodation is more stable not been asked to leave the hostel and staff are exploring independent accommodation with support Tentative attempts to build bridges with his family

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