Alcohol dependence
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Alcohol dependence



alcohol dependence and its management, on of the crucial problem ,clear cut guideline are missing

alcohol dependence and its management, on of the crucial problem ,clear cut guideline are missing



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  • discussion of Management of alcohol dependence includes comprehensive assessment and treatment , for the sake of convenience can be discussed in pretreatment, treatment and post treatment
  • Pretreatment part consists of an initial assessment which is a balance interview not only to engage the client but also to retain him in treatment, it is mainly to know the extent of problem, as assessment is a on going process so continued with the treatment
  • INITIAL –assessment should concentrated mainly three domains, (conceptualized by me for the sake of simplicity), PRESENTING COMPLAINTS , DRINKING HISTORY AND ALCOHOL RELATED PROBLEMDRINKING HISTORY includes quantity , frequency, duration , and last drink it should taken to fulfill criterias of ICD-10, DSM-1V, or what ever system we follow (SCAN, CIDI etc)Motivation should be assessed only after assessment of drinking and the extend of problem understoodThen further assessment of other problem can be done like medical , psychological, and psychiatric…along with the ongoing treatment , next is cognitive assesment
  • Level of evidence 1; evidence suggested by metaanalysis or review article from many RCT “ “ 2; at least one RCT shows evidence “ “ 3; historical studied like retrospective , or prospective studies supportes it “ “ 4 ; evidence from case series, case studiesMotivation conceptulised as stages like precontemplation , contemplation, preparation, action and maintenance
  • Other relevant investigation can be sent like USG, ECG, and blood rutine
  • this Decision making tree followed in this presentation as a step by step of management with evidence level

Alcohol dependence Alcohol dependence Presentation Transcript

  • Alcohol dependence Pharmacological management PART 1 Chairperson dr Lakshmi Pandit1 dr AJAY KUMAR
  •  PRETREATMENTP comprehensive assessment  TREATMENT acute interventions  POST TRETMENT2 dr AJAY KUMAR
  • ASSESSMENT OF MOTIVATION  Trans theoretical model(TTM)  University of Rhode island change assessment scale(URICA)  32 Items with subscale  Corresponding to the stages of changes  Readiness to change questionnaire (RTCQ)  12 items with 3 subscales corresponds to the pre- contemplation, contemplation dr AJAY KUMAR4 and action
  • Assessing alcohol related problems  Alcohol problem questionnaire(APQ)  Contains 8 domains ,44 items  Friends/money/police/physical/affective/marital/ch ildren/work  Alcohol related problem screening questionnaire  Newcastle alcohol related problems scale(NAPS)  EVIDENCE LEVEL ll5 dr AJAY KUMAR
  • Assessing psychological problem and psychiatric disorders  Depression and anxiety most common  Beck depression inventory  Beck anxiety inventory  Depression anxiety and stress scale(DASS)  Various other scale according to condition  General health questionnaire(GHQ)  Short form12 (SF12)  Beck hopelessness scale  Spielberger state trait anxiety scale  The social anxiety interaction scale  PTSD symptoms scale,17 items  Kessler 10 symptoms scale6 dr AJAY KUMAR
  • Assessment of dependence  Severity of alcohol dependence questionnaire(SADQ-C)-STOCKWELL et at 1994  < 30 indicate moderate dependence  >30 high dependence  Sort alcohol dependence data questionnaire(SADD) RAITRICK et at 1983  1-9 low  10-19 medium  >20 high  Level of evidence II7 dr AJAY KUMAR
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  • ACUTE INTOXICATION  MANAGEMENT OF ALCOHOL INTOXICATION:-  Severe intoxication req:-  1) hospital admission  2) vital signs(consciousness ,air entry, b.p.,circulation)  3) urine output , blood ethanol concentration , blood glucose level , plasma electrolytes , blood gas monitoring every 4 hrly.  4) ventilator, iv fluids , naloxone(.4mg)  5) haemodialysis  6) look for other causes of coma (trauma, narcotic drugs , meningitis)  The aim of treatment is to achieve modest lightening of12 comaKUMAR hence a safe ‘sleeping – off’ state. dr AJAY and
  •  The clinical institute withdrawal assessment of alcohol scale revised(CIWA-Ar)  <10 mild withdrawal  10-20 moderate withdrawal  >20 severe withdrawal  >10 show increase risk of complication  Scale use 1-3 times a day  Moderate-severe withdrawal if left untreated are more likely to develop complicated withdrawal(Foy et al 1988)14 dr AJAY KUMAR
  •  Alternatively ALCOHOL WITHDRAWAL SYMPTOM RATING SCALE  AWS 4 mild withdrawal  5-7 moderate  8-14 severe  >15 very severe withdrawal  Close monitoring required if AWS >10  Applied every 4 hr, if severe withdrawal then every 2 hrly15 dr AJAY KUMAR
  •  SHORT ALCOHOL WITHDRAWAL SCALE(SAWS)  Self completion  Applied every 24 hr, each question 0-4 scored16 dr AJAY KUMAR
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  •  BZDs are safe and effective for treatment of alcohol withdrawal  In general long acting BZDs with a rapid onset of action are most commonly recommended(MYO- SMITH 1997,HOLBROOK et al 1999 and review by LINGFORD-HUGHE et al 2004)  The most recent meta analysis(NAIS et al2005)has also found that BZDs are effective in reducing alcohol withdrawal symptoms, particularly in treatment and prevention of withdrawal seizure  Level of evidence la, strength A18 dr AJAY KUMAR
  •  Diazepam is BZDs of choice in many contries  Chlordiazepoxide ,a long acting and rapid onset BZDs is widely used internationally  Earlier RCT shows that lorazepam was more effective than placebo(NARAJO1998) and as effective as diazepam(MILLER& McCURDY 1983)  Long acting BZDs more effective in preventing seizure  Short acting BZDs(lorazepam, midazolam , oxazepam) used for prolong sedation, in old pt with liver disease(Myo-smith1997)  Level of evidence lll  BZDs should not continue beyond first week  Level of evidence lll19 dr AJAY KUMAR
  • SYMPTOMS TRIGGERED  Medication given only when symptoms shows moderate AW  BZDs use less in amount(SAITZ et al 1994,reoux & miller 2000)  Regimen not use for ambulatory setting or pt with h/o seizure (sail and o’Malley 1997)  Pt with liver diseased more suitable  Pt may not be appropiate for polysubstance use and with comorbidity  Level of evidence la (ll)20 dr AJAY KUMAR
  • Symptom-triggered therapy 6 5 STT dosing 4 Symptoms 3 2 1 0 Time21 dr AJAY KUMAR
  • LOADING DOSE THERAPY  a/k/a FRONT-LOADING  Administer high dose of BZDs in early stage of alcohol withdrawal  More suitable with pt who has prior h/o complicated withdrawal(SAITZ&O’MALLEY 1997)  DIAZEPAM is safe to administer in loading dose (HEINALA et al 1990)  Mostly 20 mg orally every 2hr until reaching 60- 80mg or the pt is sedated (SAITZ1997)  Level of evidence la22 dr AJAY KUMAR
  • FIXED-SCHEDULE THERAPY  It is commonly used and best suited for ambulatory withdrawal ,community residential and inpt withdrawal setting(sailz&O’Malley1997)  This schedule may supplemented additional diazepam  Pt with concomitant medical, psychiatric or substance use disorder a fixed schedule therapy is more apprpiate  Lenel of evidence la(ll)23 dr AJAY KUMAR
  • Symptom-triggered vs. fixed dose 6 5 STT dosing Fixed dosing 4 Symptoms 3 2 1 0 Time24 dr AJAY KUMAR dr AJAY KUMAR 24
  •  Elecetrolyte correction  Hypokalaemia and hypomagnesaemia should be corrected by oral supplimentation(saitz&O’Malley1997)  Hyponatremia should not be corrected aggressively Thiamine supplement  Recommended for all(cook2000)  According to recent cochrance review there is insufficient evidence from RCT(DAY et al 2004)  Existing recommendation (Thomson et al 2002;Lingford-Hughes et al 2004)  300mg per day(100mg tds)for 3-5 d,and oral 100mg for next 4-9days  Multivitamin preparation can be given for several days(Myrick&Anton1998)25 dr AJAY KUMAR
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  • Treatment of severe withdrawal complication  50% of seizure occure in 13-24 hr and 90% occurs with in 48hr  GTCS type (Rueff1995 )  New onset alcohol withdrawal seizure related to heavy alcohol consumption(Hillbom et al 2003)  Diazepam loading is recommended27 dr AJAY KUMAR
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  •  Pt should be admitted in to a supervised withdrawal settings for at least 48-72 hr  Monitor for vitals , alcohol withdrawal symptoms,  Thiamine 100mg tds  Supportive measurements including nursing in a quiet environment away from excessive sensory stimuli and rehydration should be provided  Diazepam loading (levell)  Pt should not be initiated on long term anticonvulsant unless there are other cause of seizure31 dr AJAY KUMAR
  • Alcohol withdrawal delirium  Disturbance of consciousness and change in cognitive or perceptual disturbance developing in a short periode of time during or shortly after alcohol withdrawal syndrome (APA2002)  Accompanied by other symptoms of withdrawal like high fever, tachycardia, hypertension, diaphoresis(Myo-Smith et al 2004  Concomitant medical condition like dehydration, electrolyte abnormalities , renal failure , unrecognized head trauma, infection , liver failure32 dr AJAY KUMAR
  •  hospitalize  Initial treatment to control agitation  Sedative hypnotics found more effective than neuroleptics (Myo-Smith et al 2004)  Relative risk of mortality with neuroleptic treatment as compaired with sedative-hypnotcs were 6.6  Parenteral dose of rapid acting BZDs for agitation control –to maintain light somnolence  Parenteral diazepam, midazolam used for rapid sedation( la;A)  Magnesium administration may help in reducing NM activity(Saitz & O’Malley1997)33 dr AJAY KUMAR
  • WERNICKE’S KORSAKOFF’S SYNDROME  Normal person absorbed 4.5% as compared to chr alcoholic who absorbed 1.5% of oral thiamine  Clinical triad  Confusion-80%  Ataxia-20-25%  Eye sign 30%  Only 10% has triad34 dr AJAY KUMAR
  •  Diagnostic test of WE is MRI(Sechi & serra 2007)  Shows asymmetric alteration in mamillary bodies, medial thalami , tectal plate and periaqueductal area(CHUNG et al 2003;Estruch et al 1998;sechi and serra2007)  Level of evidence lll  MRI has low sensitivity (53%) but high specificity(93%) for WE (ANTUNEZ et al 1998)  Early diagnosis of WE done by MR fluid-attenuated inversion recovery(FLAIR) sequence and diffusion- weighted MRI(SULLIVAN & PFEFFER BAUM2009)35 dr AJAY KUMAR
  •  Thiamine given BEFORE any carbohydrate loading(iv glucose)  Parenteral dose of at least 500mg per day IM/IV diluted in saline over 30 min  Then 300mg per day for 1-2 wk  Level lll evidence  For persistence drinker 100 mg per day36 dr AJAY KUMAR
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  • Alcohol withdrawal uncomplicated complicate d seizure wks delirium stabilize Deterrent Antagonist Agonist Antic raving DISULFIRAM BROMOCRIPTINE NALTREXON ACAMPROSAT E E38 dr AJAY KUMAR
  •  Disulfiram, NTX, acamprosate are the approved by US FDA  Disulfiram most commonly used alcohol sensitizing agent approved in 1948  MOA  Inhibit alcohol dehydrogenase (LARSON et al1992)  Aldrehyde concentration increased to 5- 10times(CHICK et al 1999)  Became effective in 3-12 hr and remains effective for 1-2wks39 dr AJAY KUMAR  Std dose 250(125-500)mg
  •  SIDE EFFECT –drowsiness , gastric irritation  Adverse effect- hepatic, neurological, skin reaction and psychosis  Regime 250 mg per day after informed consent  COMPLIANCE AND EFFICACY  Series of studies reported definite efficacy in supervised regimen by spouse called community reinforcement therapy(CRT) AZRIN et al 1982  Confirmed by CHICK et al 1992 in multi centre British study40 dr AJAY KUMAR
  • Points DSF NTX ACAM Mech Aldehyde Unknown. ↓ glutamate at of Dehydrogena ?Blocking NMDA action se inhibitor; endogeno receptors, aversive us opioids ↓ Ca++ flux, NA, opiates, ↑ 5-HT, GABA41 dr AJAY KUMAR
  • DSF NTX ACAM Dose 125-500 mg 50 mg OD; 1.3 or 2g OD 3-6 months /day in 3 for 1 yr divided doses ;1 yr Serious Hepatotoxic Opioid Absent S/Es , withdrawal Psychosis, Sx, neuropathy, Hepatotoxicity Interact +++ ++ Absent ions Cost AJAY KUMAR 2-5 dr Rs Rs 40-48 Rs 20- 3042
  • DSF NTX ACAM Low  Anti  No interactions with cost craving Drugs/ alcohol OD  OD dose  Can be used in dose  Also hepatic impairment useful for  Best S/E profile Opioid &  Can be combined nicotine with DSF/NTX  Impulse  Does not Cause control opioid withdrawal SX43 dr AJAY KUMAR
  • DSF NTX ACAM  High motivation  Costly  Cost  Aversive  S/E  TID dosage therapy   life threatening Interactions interaction with alcohol  S/E & interactions44 dr AJAY KUMAR
  •  US survey revealed ,9% of people needing treatment for ADS receive medication for relapse prevention, prescription of D.S decline by 3% between 2003-2007 while NTX rise to by 3% and ACAMPROSATE by 10%(MARK et al 2009)  ACAMPROSATE+NALTREXONE  Two trial comparing combination and individual drug with placebo  KIEFER 2003 AND ANTON 2006  There is no significant difference between the combination of acamprosate and naltrexone and45 either drug alone dr AJAY KUMAR
  •  DOPAMINE- important in reward pathway (KOOB & VOLKOW 2010)  Released by cues , motivate to take more substance (SCHULTZ 2007)  Bromocriptine  Disulfiram action on dopamine system  Increased endorphin by alcohol  Naltrexone given promising result (DROBES et al 2005)46 dr AJAY KUMAR
  •  GAMMA AMINOBUTYRIC ACID-GLUTAMATE SYSTEM  Drug acting on this system have been shown to reduce drug linking and seeking (COUSIN et al 2002)  BACLOFEN is a medication that has long been used to treat muscle spasm and acts on GABA-B agonist recently proposed and reported efficacy in relapse prevention (ADDOLORATO et al 2007)47 dr AJAY KUMAR
  •  GLUTAMATE–excitatory system  Modulate dopamenergic reward pathway  ACAMPROSATE normalize balance (LITTLETON 2000)  MEMANTINE a antagonist of one glutamate receptor NMDA investigated but not shown efficacy in preventing relapse(EVAN et at2007)  Several anticonvulsant are tried most evidence currently being for topiramate (JOHNSON et al 2007)  Gabapentine and pregabaline use  Pregabaline interact with a2d inhebite glutamate48 (LANDMARK2007) dr AJAY KUMAR
  •  SEROTONIN- early onset alcoholics( <25yr) reduced serotonergic system They are impulsive ,ASPD , family h/o alcoholism often male(CLONINGER et al 1981) Also has bulimia, depression, anxiety, OCD  So SSRIs tried in ADS  BUSPIRONE- a 5HT1A partial agonist Both buspirone and SSRIs found to reduce alcohol in animal models –JOHNSON 2008  5HT3 a modulator of dopaminergic reward pathway, ONDANSTRON an antagonist show efficacy in alcoholism(JOHNSON et al 2000)49 dr AJAY KUMAR
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  • reference • Alcohol use disorder –the NICE guideline on diadnostsis and assessement of harmful drinking and alcohol dependence NATIONAL CLINICAL PRACTICE GUIDELINE-115(british psycological society and royal college of psychiatry) • A review of literature :Incorporating Alcohol Pharmacotherapy in to mental practice(U.S dept of health and human services) • Guideline for the treatment of alcohol problems(National Drug and Alcohol Research centre) oct -0352 dr AJAY KUMAR
  • Reference contd….  Prescribing guidelines ,10th edition, The Maudsley  Textbook of post graduated psychiatry ,2nd edition ,JN Vyas ,Niraj Ahuja  Neuroradiology /head and neck imaging ;ajp;192 feb 2009  A review of screening assessment and outcome measures for drug and alcohol setting –Mark Deady ;NADA 2009  Management of alcohol withdrawal delirium ;An evidence based practical guideline ;Mayo- dr AJAY KUMAR53 smith, Arch intern Med 2004;164; 1405-1412
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  • (When you click timer, an alert box will be displayed after 2 minutes) Simple Rey-Osterrieth Complex Figure Test This test, designed by the Swiss psychologist André Rey in 1941, will allow you to assess your spatial perception and your visual memory. Observe the drawing above for approximately 2 minutes, then try to reproduce it from MEMORY. Score Score 2 points for each drawn element remembered correctly: a complete straight line or a circle. There are in all 44 straight lines and circles that compose the drawing. 76 to 88 points indicate that you have an excellent memory, 60 to 74 points indicate that you have a good memory, 46 to 58 points mean that you have an average memory. If you have less than 46 points, you should read more puzzle books/magazines to boost your brain! Anyway, don’t worry, there are many other empirical scoring systems to quantify the accuracy of the drawing.65 dr AJAY KUMAR