Alcohol addiction is a chronic illness

AN INTEGRATED APPROACH TO THE PATIENT: INCORPORATING MEDICATION INTO THE TREATMENT PLAN * Louise Epperson, MSN, CRNP ABSTRACT Individuals attempting to withdraw from their dependence on alcohol are best served by the support of a multidisciplinary team working in conjunction with significant others, such as family or friends. The clinical team may choose from a variety of tools to assist alcohol-dependent persons, often using a holistic approach that incorporates both pharmacologic and nonpharmacologic therapies. This article describes eligibility criteria for outpatient detoxification, including assessment tools for determining if a patient is well-suited to this management plan as well as models of psychosocial support and specific treatment recommendations. Factors in treatment retention, such as medication nonadherence, are also addressed. (Adv Stud Nurs. 004;():0-) *Based on a presentation given by Ms Epperson at the 00 Southeastern Conference on Alcohol and Drug Addiction. Director, Detoxification and Primary Care Services, Treatment Research Center, University of Pennsylvania, Philadelphia. Address correspondence to: Louise Epperson, MSN, CRNP, Treatment Research Center, University of Pennsylvania, 900 Chestnut Street, Philadelphia, PA 19104. E-mail: epperson_l@mail.trc.upenn.edu. Alcohol addiction is a chronic illness that may be marked by periods of relapse and remission. As such, it poses challenges not only to the patient but also to the family, significant others, and healthcare providers entrusted with the task of assisting the patient to overcome his or her drinking problem. As with other similarly serious and lifelong conditions, the best approach is often an integrated one that incorporates the use of a multidisciplinary team using various pharmacologic and nonpharmacologic techniques. The nurse is an integral member of the team, providing a support system with which the person can bond and, depending on the nurse s area of expertise, providing psychotherapeutic support and/or evaluating and treating the medical sequelae that may accompany chronic alcohol ingestion. Perhaps the most important role of the multidisciplinary team treating alcohol addiction (which, apart from nurses, may also comprise physicians, social workers, and support staff) is to chart a recovery course for the alcohol-dependent patient, beginning with detoxification. Goals include attaining abstinence while minimizing withdrawal symptoms and complications and avoiding relapse after alcohol has been eliminated. The last goal is long term and requires ongoing monitoring and treatment. 1 In the following sections, treatment options are discussed, including how to evaluate whether an individual is an appropriate candidate for outpatient therapy, what types of nonpharmacologic strategies are available, and how to incorporate medication into the treatment plan. 0 Vol., No. April 004

TAKING THE FIRST STEP: DETERMINING WHO IS ELIGIBLE FOR OUTPATIENT DETOXIFICATION Outpatient detoxification is appropriate for individuals with mild-to-moderate alcohol withdrawal who are both medically and psychiatrically stable (neither suicidal nor homicidal). These patients must have a stable residence (which can include a shelter under certain circumstances but not an emergency shelter) and are ideally best treated when supported by a sober relative or friend. If they have attempted to withdraw from alcohol in the past, these patients may be able to do so again on an outpatient basis if there is no history of delirium tremens or epilepsy. The severity of withdrawal symptoms increases with each withdrawal episode, and % to % of heavy chronic drinkers experience severe withdrawal symptoms (grand mal seizures, delirium tremens). Even with treatment, mortality is about 1% and is usually caused by cardiovascular collapse or concurrent infection. Therefore, clinicians should assess for preexisting alcohol withdrawal seizures and use caution when considering outpatient detoxification. Finally, patients considering outpatient detoxification must be able to either self-administer (and tolerate) oral medications or have a competent and reliable person to assist with this effort. 1 A thorough intake assessment is needed to determine if an individual fits these criteria. This assessment includes a health history and physical examination to evaluate whether symptoms of alcohol withdrawal are present (eg, change in vital signs, including increased blood pressure, pulse, and temperature; nausea; diaphoresis; restlessness; anxiety; headache; tremor; or seizures). Clinicians must also determine whether more serious indications of withdrawal are evident, signaling the onset of delirium tremens, such as confusion, fever greater than 100 F, hallucinations, and severe agitation. Other key information to obtain includes questioning the individual about the concomitant use of prescription and over-the-counter medications, including vitamins and herbal supplements. Regarding physical concerns, in the review of systems, patients should also be asked about their frequency of visits to the emergency department, as multiple trauma is not uncommon in this population (recent head trauma precludes outpatient detoxification). Gastrointestinal disorders are also common, especially active bleeding ulcers, which would also preclude the option of outpatient treatment. Finally, it is important to discuss previous abstinence experiences with the patient and his or her family to determine how he or she fared and specifically if the patient had serious complications, such as seizures or hallucinosis. On physical examination, specific areas for assessment for the alcohol-addicted patient include a breathalyzer test result and a urine toxicology sample to screen for the presence of coexisting substance abuse. This type of screening may make a difference in terms of whether the patient may still be managed as an outpatient and what type of chemotherapeutic agents can be selected to safely assist in withdrawal from alcohol. This or other comorbid psychiatric and/or serious physical problems dictate what to expect and plan for in outpatient detoxification. The presence of unstable psychiatric conditions (eg, untreated bipolar disorder), recent head injury or stroke, or unstable heart problems, make the individual unsuitable for detoxification in the outpatient setting. Findings on the physical examination that are not compatible with outpatient treatment include marked ataxia or significant nausea with vomiting. OUTPATIENT DETOXIFICATION: THE PROCESS Withdrawal severity and indications for pharmacotherapy can be assessed using the Clinical Institute Withdrawal Assessment for Alcohol, Revised (see page ). 4 The need for medication in the outpatient who is withdrawing from alcohol is determined by the signs and symptoms exhibited by that individual. It therefore may be more desirable to administer pharmacotherapy individualized to that patient rather than on a fixed schedule to safely provide for the patient s comfort while keeping the time of withdrawal treatment shorter. Because these withdrawal symptoms may originate due to changes in the biochemistry of the brain, (specifically in alterations of certain neurotransmitters and pathways within the mesocorticolimbic system), medications that target these specific neurotransmitters may be most effective. Mayo-Smith performed a meta-analysis to provide evidence-based practice guidelines for the pharmacologic management of alcohol withdrawal. The author reviewed data from 14 articles from 19 through June 199, which included prospective controlled trials involving 4 different medications. Benzodiazepines were found to be suitable agents for Advanced Studies in Nursing 1

CLINICAL INSTITUTE WITHDRAWAL ASSESSMENT OF ALCOHOL SCALE,REVISED (CIWA-AR) Patient: Date: Time: (4-hour clock, midnight = 00:00) Pulse or heart rate, taken for 1 minute: Blood pressure: NAUSEA AND VOMITING Ask Do you feel sick to your stomach? Have you vomited? Observation. 0 no nausea and no vomiting 1 mild nausea with no vomiting 4 intermittent nausea with dry heaves 7 constant nausea, frequent dry heaves and vomiting TREMOR Arms extended and fingers spread apart. Observation. 0 no tremor 1 not visible, but can be felt fingertip to fingertip 4 moderate, with patient's arms extended 7 severe, even with arms not extended PAROXYSMAL SWEATS Observation. 0 no sweat visible 1 barely perceptible sweating, palms moist 4 beads of sweat obvious on forehead 7 drenching sweats ANXIETY Ask Do you feel nervous? Observation. 0 no anxiety, at ease 1 mildly anxious 4 moderately anxious, or guarded, so anxiety is inferred 7 equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions AGITATION Observation. 0 normal activity 1 somewhat more than normal activity 4 moderately fidgety and restless 7 paces back and forth during most of the interview, or constantly thrashes about TACTILE DISTURBANCES Ask Have you any itching, any pins and needles sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin? Observation. 0 none 1 very mild itching, pins and needles, burning, or numbness mild itching, pins and needles, burning, or numbness moderate itching, pins and needles, burning, or numbness 4 moderately severe hallucinations severe hallucinations extremely severe hallucinations 7 continuous hallucinations AUDITORY DISTURBANCES Ask Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing to you? Are you hearing things you know are not there? Observation. 0 not present 1 very mild harshness or ability to frighten mild harshness or ability to frighten moderate harshness or ability to frighten 4 moderately severe hallucinations severe hallucinations extremely severe hallucinations 7 continuous hallucinations VISUAL DISTURBANCES Ask Does the light appear to be too bright? Is its color different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things you know are not there? Observation. 0 not present 1 very mild sensitivity mild sensitivity moderate sensitivity 4 moderately severe hallucinations severe hallucinations extremely severe hallucinations 7 continuous hallucinations HEADACHE, FULLNESS IN HEAD Ask Does your head feel different? Does it feel like there is a band around your head? Do not rate for dizziness or lightheadedness. Otherwise, rate severity. 0 not present 1 very mild mild moderate 4 moderately severe severe very severe 7 extremely severe ORIENTATION AND CLOUDING OF SENSORIUM Ask What day is this? Where are you? Who am I? 0 oriented and can do serial additions 1 cannot do serial additions or is uncertain about date disoriented for date by no more than calendar days disoriented for date by more than calendar days 4 disoriented for place or person The CIWA-Ar is not copyrighted and may be reproduced freely. Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM. Assessment of alcohol withdrawal: the revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale. Br J Addiction. 1989;84(11):1-17. 4 Patients scoring less than 10 do not usually need additional medication for withdrawal. Total CIWA-Ar Score Rater's Initials Maximum Possible Score 7 Vol., No. April 004

alcohol withdrawal, with choice of agents guided by duration of action, rapidity of onset, cost, and potential for abuse. The investigators determined that in some circumstances, long-acting agents are more desirable, because they may cause less rebound symptoms between doses. Short-acting benzodiazepines, however, are less likely to cause oversedation. Two safe agents of choice in outpatient detoxification are the long-acting benzodiazepines oxazepam and clonazepam. They permit a dosage schedule that facilitates compliance because they need to be taken only every 4 to hours in the case of oxazepam and every 8 to 10 hours in the case of clonazepam. Oxazepam is metabolized in the kidney but conjugated in the liver; even if the patient has preexisting liver disease, assuming the liver function tests look unremarkable, this agent is safe to use. Clonazepam, though metabolized by the liver, may be necessary for the patient who is in more severe alcohol withdrawal or who has comorbid abuse of some sedatives. Because its half-life is 4 hours and it is longer acting, clonazepam requires less frequent dosing and possibly reduces anxiety in sicker patients. In addition to administration of pharmacotherapy, patients undergoing outpatient detoxification must also agree to attend structured visits (generally times per week) as specified in a patient contract, which also sets other expectations for the patient. Such contracts outline the responsibilities of both parties (patient and clinical team) as well as provide practical information to the individual who has agreed to manage his or her care in the real world. For example, the contract may include emergency contact numbers and explicit information about medications, such as what will happen if alcohol is ingested along with benzodiazepines. To monitor how patients are progressing as outpatients, various baseline laboratory tests should be obtained. These include breathalyzer monitoring on each visit and laboratory tests, including complete blood counts to assess anemia, thrombocytopenia, mean corpuscular volume, a chemistry panel (for kidney and liver function), pregnancy, and urinalysis testing, as well as a baseline toxicology screen. Additional laboratory tests that may be useful in some circumstances include hepatitis screening and coagulation panels in those in whom serious hepatic impairment is suspected and/or thyroid testing when patients present with concomitant mood disorders, such as depression. In to 7 days, the patient will be ready to transition from outpatient detoxification to postdetoxification psychosocial treatment (sometimes supplemented with medication) to remain alcohol free. During this period, detoxification medications are tapered and laboratory values are reviewed to ensure the individual is medically stable and to plan for the future. If patients are unable to successfully complete ambulatory detoxification, they can be referred to an inpatient program or residential treatment facility if the environment was not suitable for them to attain initial sobriety. Patients who make the transition into the next phase of outpatient treatment will begin a program of outpatient psychosocial support. There are several models from which to choose. MODELS OF PSYCHOSOCIAL SUPPORT The various models of treatment for the recovering alcohol-dependent patient include individual and group therapies. Selection of a specific intervention varies and may be based on the severity of the alcohol problem, presence of comorbid medical and psychiatric problems, and patient motivation to change. In 1998, data from Project MATCH (Matching Alcoholism Treatment to Client Heterogeneity) determined that the major types of state-of-the-art psychosocial treatments available at the time of the study were all equally but only moderately effective, helping approximately 0% of the 1700 randomly assigned subjects to cut down on their drinking days from 7% to 0% after months of therapy. 7 A brief discussion of these types of interventions, cognitive behavioral coping skills therapy (CBT), motivational enhancement therapy (MET), and 1-step faciliation, follows. In addition, new models, such as medical management (compliance enhancement) and BRENDA are discussed. INDIVIDUAL COUNSELING: COGNITIVE BEHAVIORAL AND MOTIVATIONAL ENHANCEMENT Motivational Enhancement Therapy. MET begins by building the client s motivation. It explores and reflects client perceptions while avoiding labels. For example, this type of therapy is suited to the type of individual who dislikes being told, You re thinking negatively. This is what you ought to do. Instead, MET leaves it up to the patient and his or her significant other(s), when appropriate, to problem solve, develop strategies for changing behavior, and be responsible for change. There is no unsolicited advice from the therapist, nor is Advanced Studies in Nursing

there any training, modeling, or practice. Results from Project MATCH suggested that this type of therapy works well for alcohol-dependent people who have high levels of anger during the year following treatment.,7 CBT Assumes motivation; no direct strategies Seeks to identify and modify maladaptive cognitions Offers coping strategies and problem solving Teaches coping behaviors by modeling, directed practice, and feedback Therapy: CBT or MET? MET Uses specific strategies to build client motivation Explores and reflects client perceptions; no labels Strategies and problem solving from client and significant other(s) Client and significant other(s) responsible for change; no training, modeling, or practice CBT = cognitive behavioral therapy; MET = motivational enhancement therapy. Data from the Project MATCH Research Group. 7 Cognitive Behavioral Coping Skills Therapy. The aim of CBT is to teach patients to recognize and cope with high-risk situations for relapse through role play and rehearsal. Although CBT and MET are both forms of individual therapy, there are some important differences between these approaches and the types of clients for whom they are suitable. CBT assumes that the individual is motivated to change and provides no direct strategies to assist with this process, whereas MET uses specific strategies to build client motivation. CBT seeks to identify and modify maladaptive cognitions. Thus, it is a useful therapy for patients who are by nature negative and pessimistic to teach them positive self-talk. It offers coping strategies and problem solving, teaching coping behaviors by modeling, directed practice, and feedback. CBT teaches clients to recognize and cope with high-risk situations for relapse and to recognize and cope with cravings for alcohol by role playing and rehearsing such scenarios. 1-STEP FACILITATION PROGRAMS While many 1-step facilitation programs have been developed over the years to assist people in addressing many types of issues in their lives, the very first program of its kind originated with Alcoholics Anonymous in the 190s. Alcoholics Anonymous elucidates 1 steps that recovering alcohol-dependent patients need to work through to achieve recovery. The philosophy underlying the program is spiritual in nature (although it does not necessarily rely on a belief in one specific religion). These programs offer newly recovering alcohol-dependent patients a safe place to discuss problem drinking with others who have been through the same or similar difficulties as well as a partner who has successfully eliminated alcohol abuse and to whom the person can turn when he or she needs support. Although all alcohol-dependent patients should be encouraged to consider a group therapy of this type as an adjunct to individual counseling and/or pharmacotherapy, 1-step facilitation programs seem to be particularly suited to individuals who are poor, isolated, and lonely or who need positive role models to support them in their sobriety.,7 NEW APPROACHES: COMBINED PHARMACOTHERAPY AND BEHAVIORAL INTERVENTIONS While medications like naltrexone may be pharmacologically effective in reducing the pleasurable effects of alcohol, just as antihypertensive medications may be effective in decreasing blood pressure, their clinical effects are completely reliant on adherence to the medication regimen. In the case of alcohol dependence, clinical effectiveness of pharmacotherapy depends on the motivation of the person to abstain from alcohol and adhere to the prescribed regimen within the context of many complicating psychosocial issues. The medical management and adherence enhancement behavioral interventions were developed specifically for the Combining Medications and Behavioral Interventions (COMBINE) study, a large-scale, multicenter, randomized, controlled clinical study comparing naltrexone and acamprosate with placebo. 8 The purpose of the study was to evaluate the feasibility of a combined therapy (medication and behavioral therapy) approach. The goal of these behavioral interventions is to support the use of effective pharmacotherapy for alcohol dependence. Medical management provides education, optimistic support, and strategies to achieve and maintain sobriety. It offers expert assessment and direct advice, using reason and common sense to preserve and restore health. It is not psychotherapy. Based on the pilot study, larger-scale studies using these methodologies appear feasible. 8 4 Vol., No. April 004

BRENDA MODEL The BRENDA Model was developed by the University of Pennsylvania Treatment Research Center and is derived from motivational interviewing techniques and theories about human stages of change developed by Prochaska and DiClemente s Stages of Change Model. BRENDA utilizes an acronym to describe the various stages of therapy used to improve adherence. 9,10 The first step, Biopsychosocial evaluation, allows the clinician to understand the presence of any comorbid physical or psychiatric conditions that may affect the goal of abstinence. This is followed by Report/responsibility, during which the clinician provides feedback to the client as to how his or her drinking is affecting himself/herself and others. In the third step, Empathy, the clinician reveals that he or she understands that maintaining sobriety is not an easy task. During this stage, however, the clinician must try to understand what the patient is experiencing in order to help set goals that are important in the individual s The BRENDA Model Biopsychosocial evaluation Report to patient on assessment Empathetic understanding of the patient s problem Needs derived in collaboration with the patient Direct advice given to the patient Assess response to advice and adjust as necessary Data from Volpicelli et al. 9 specific situation rather than generic goals. For example, most central to the patient s need to stop drinking may not be liver damage but the inability to pay the mortgage and danger of losing his or her home. This empathy dovetails into the next phase, which is Needs assessment/goals. Goals are set based on what the patient determines his or her needs and goals are, rather than being dictated by the therapist. What if these goals are unrealistic? This is a time when the therapist may move on to the next phase, giving Direct advice. Advice is administered without confrontation and may include advising the use of medication, suggesting group therapy, or negotiating an unrealistic drinking goal to make it more realistic. In the final phase of BRENDA, the Assessment phase, the response to direct advice is determined. It may be that the client is not ready for change, and the therapist may have to continue to work with the individual to attain the stage where the patient can accept and follow through with concrete advice to improve his or her situation. 9,10 PUTTING IT ALL TOGETHER: TREATMENT RECOMMENDATIONS In this review, we have discussed the role of the multidisciplinary team, criteria for selecting candidates suitable for successful outpatient detoxification, and how through the use of psychosocial therapies and medication (where appropriate), individuals may be assisted in their recovery from alcohol dependence. This is a monumental task at times, because alcohol dependence is a chronic disease that insinuates itself into a young population (40% of alcohol-dependent patients experience their first symptoms between ages 1 and 19 years), is frequently undiagnosed (screening in the primary care setting occurs less than 0% of the time), and is marked by a high rate of recidivism (about 0% of alcoholdependent patients relapse in the first year). 11,1 How then, can we stack the deck in our favor? It is helpful to prescribe several types of behavioral therapies and/or medications based on the assessment made of the patient. For example, undiagnosed psychiatric conditions may cause patients to discontinue treatment, as could symptoms derived from protracted abstinence syndrome, such as insomnia, anxiety, or irritability. Medications that target the pleasurable effects or cravings for alcohol (such as naltrexone or topiramate) or treat comorbidity such as depression (like the SSRIs) help, but patients must be assisted in adhering to their medication regimen. Nonadherence may result from a lack of understanding of how the medication works, its side effects, and forgetting to take or feeling uneasy about taking medications either due to bad experiences in the past or denial that the problem is serious enough to require pharmacotherapy. Other barriers to treatment may include decreased motivation to stay sober, addiction to other substances, a poor family support system, or inadequate availability of continuing professional treatment. These barriers can be overcome through a therapeutic alliance that fosters collaboration and the Advanced Studies in Nursing

resources of specialists from a variety of disciplines, primarily psychiatry and social work as well as nursing and medicine. Because certain types of therapy (eg, combined behavioral intervention or family therapy) engage family and significant others to a greater extent than others, selection of the type of therapy that best suits the patient s psychosocial situation is imperative. From a nursing perspective, simply educating patients about what to expect in terms of medication effects including the time frame during which a medication will begin to take effect, side effects, and whether side effects are temporary and counseling patients on what cues to use to assist themselves to remember to take their pills can make a tremendous difference in treatment efficacy. Whether outpatient or inpatient detoxification is ultimately utilized, care plans for the alcohol-dependent patient should also include assessment of ageappropriate health maintenance issues, because this population is often at risk for neglecting general health. Nurses may provide counseling not only for alcohol but also for other common addictions, such as smoking, that place the alcohol-dependent client at high risk for other serious medical conditions, such as cancer and cardiovascular disease. Poor eating frequently accompanies drinking; as part of the integrated approach to the patient, nurses can discuss nutritional issues to help the individual focus on improving diet to reduce the risk of malnutrition, vitamin deficiency, and osteoporosis. Successfully overcoming alcohol addiction frequently means treating the whole person and sometimes the whole family. REFERENCES 1. Kosten TR, O Connor PG. Management of drug and alcohol withdrawal. N Eng J Med. 00;48(18):178-179.. Enoch MA, Goldman D. Problem drinking and alcoholism: diagnosis and treatment. Am Fam Physician. 00;():441-448.. Thompson W. Alcoholism. emed Med Libr. 00. Available at: http://www.emedicine.com/med/ topic98.htm. Accessed January 17, 004. 4. Sullivan JT, Sykora K, Schneiderman J, Naranjo CA, Sellers EM. Assessment of alcohol withdrawal: the revised Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale. Br J Addict. 1989;84(11):1-17.. Mayo-Smith MF. Pharmacological management of alcohol withdrawal: a meta-analysis and evidence-based practice guideline. American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal. JAMA. 1997;78():144-11.. McNamara J. Drugs effective in the therapy of the epilepsies. In: Hardman JG, Limbird LE, Molinoff PB, Ruddon RW, Gilman AG, eds. Goodman and Gilman s Pharmacological Basis of Therapeutics. 9th ed. New York: McGraw-Hill; 199:41-48. 7. Project MATCH Research Group. Matching alcoholism treatments to client heterogeneity: treatment main effects and matching effects on drinking during treatment. J Stud Alcohol. 1998;9():1-9. 8. The Combine Study Research Group. Testing combined pharmacotherapies and behavioral interventions for alcohol dependence (The COMBINE Study): a pilot feasibility study. Alcohol Clin Exp Res. 00;7(7):11-111. 9. Volpicelli JR. Alcohol abuse and alcoholism: an overview. J Clin Psychiatry. 001;(suppl 0):4-10. 10. Kaempf G, O Donnell C, Oslin DW. The BRENDA model: a psychosocial addiction model to identify and treat alcohol disorders in elders. Geriatr Nurs. 1999;0():0-04. 11. Helzer JE, Burnam A, McEvoy LT. Alcohol abuse and dependence. In: Robins LN, Regier DA, eds. Psychiatric Disorders in America: the Epidemiological Catchment Area Study. New York: Maxwell Macmillan International; 1991:81-11. 1. Fleming MF. Strategies to increase screening in healthcare settings. Alcohol Health Res World. 1997;1:40-47. Vol., No. April 004