Management of Alcohol Dependence
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Here we are discussing management of Alcohol use disorder and it's various complications.
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Management of Alcohol Dependence
- 1. Management of alcohol dependence DR GANESH INGOLE RESIDENT PSYCHIATRY 1
- 2. ALCOHOL Intoxication Withdrawal syndrome Simple withdrawal Alcohol induced seizures Alcohol induced psychosis Delirium tremens Neuropsychiatric complications Methanol poisoning Relapse prevention Pharmacological management Psychotherapy 2
- 3. TREATMENT OF ALCOHOL INTOXICATION Immediate attention to vital signs Airway protection (Check for CHOCKING & ASPIRATION) Make the patient lie prone/lateral position Hydration status, I.V. fluids, electrolytes Symptomatic control of nausea and vomiting Thiamine supplementation (before glucose administration) Glucose administration (glucose measurement) 3
- 4. Initial assessment Patterns of drinking Previous alcohol withdrawal episodes Last drink Other substance use Comorbid medical and psychiatric assessment Physical examination Laboratory investigations 4
- 5. Assessing dependence Alcohol use Disorder Identification Test (AUDIT) 10 item, Maximum total score= 40 8 or more than 8- Harmful or Hazardous drinking Severity of Alcohol Dependence Questionnaire (SADQ) 20 item, Maximum total score=60 Mild=15 0r less, Mod=15-30, Severe >30 5
- 7. Simple withdrawal-Alcohol Detoxification Input- output charting Pulse, BP and Temperature charting Fluid replacement Oral intake Ensure Inj Thiamine before Glucose administration IV fluids- preferable RL or NS Correct electrolyte imbalance (hypokalemia, hypomagnesemia, hyponatremia) 7
- 8. Alcohol Detoxification Pharmacological detoxification CIWA-Ar score > 15 SAWS score >12 Community based Good social support, Mild dependence Inpatient Severe dependence Complicated withdrawal Co morbid illness 8
- 9. Drugs- Benzodiazepines Benzodiazepines – drug of choice Clordiazepoxide – most preferred, long acting Hepatic impairment- Oxazepam, lorazepam Rule of thumb- 20 u/day= 20 mg qid of Librium OR 5mg of Diazepam equivalent for one std drink Diazepam 5 mg= Chlordiazepoxide 25 mg= Lorazepam 1 mg= Oxazepam 15 mg 9 Shivanandan K, B Bharadwaj, Clinical management of alcohol withdrawal a systemic review, Industrial journal of Psychiatry, Dec 2013
- 10. Withdrawal Regimens Fixed dose reduction Mostly for Community based Non specialist setting Variable dose reduction Specialist settings- Regular monitoring Symptoms triggered regimen Front loading regimen Initial loading dose of 100mg Further doses of 50-100m g every 4-6 hrs till light sedation 10
- 11. Thiamine High risk -Inj Thaimine – 500 mg/day*5 days Must be given before glucose Wernicke’s encephalopathy- Prophylactic- - IV infusion once daily for 3-5 days Established or presumptive-1000mg/d for 3-5 days f/b 500mg/day for 3-5 days Korsakoff’s psychosis- permanent damage Low risk- Oral Thiamine 300mg/ day 11
- 12. Other medications Barbiturates (phenobarbitone) Dehydration- adequate fluid Pain- Paracetamol Nausea/vomiting- Metoclopromide/prochlorperazine Diarrhoea- Diphenoxylate, atropine, loperamide Beta blockers Clonidine 12
- 13. Complicated withdrawal- Seizures Investigations to rule out organic aetiology Longer acting BZD Carbamazapine- comparable efficacy with BZD Previous history of seizures H/o seizure despite adequate BZD cover Other agents Oxcarbazapine Levetiracetam Pregabalin 13
- 14. Complicated withdrawal- Hallucinations BZD-Chlordiazepoxide preferred Alcohol induced Psychosis- self limiting Haloperidol Oral or injectable Risk of lowering seizures threshold 14
- 15. Complicated withdrawal- Delirium Tremens Input- output charting Pulse, BP and Temperature charting Beta blockers - BP >180mmof Hg IV Diazepam Fluid and electrolytes Inj Thiamine Other medications- Baclofen, ethyl alcohol, lamotrigine, magnesium 15
- 16. Methanol Poisoning Clinical features- nausea, vomiting, abdominal pain and visual symptoms (falling visual acuity, photophobia) Maintain airway, breathing and cardiovascular stability Vitamin supplementation Gastric lavage - within 1-2 hours of ingestion Seizures - phenytoin (250mg IV over 5min)-less CNS depressant effect than diazepam Specific antidote - ethanol Hemodialysis - renal impairment or any visual impairment Correction of metabolic acidosis with NaHCO3 16
- 17. Relapse prevention Pharmacological Deterrent agent Anticraving agents Psychotherapies 17
- 18. Deterrent agent- Disulfiram Indications Motivation to quit alcohol No craving External factors as the reason for relapse Committed to be abstinent Supervision possible Predisulfiram checklist Informed consent Last alcohol use more than 2 weeks ago Normal LFT Absence of neuropathy/ psychosis 18
- 19. Deterrent agent- Disulfiram contd. Regular BP monitoring LFT once in 6 months Remain abstinent for minimum 2 weeks after last dose Explain Disulfiram ethanol reaction to patient Symptomatic management 19
- 20. Anticraving agents Naltrexone Acamprosate Topiramate Baclofen SSRIs Newer agents 20
- 21. Naltrexone Indications Early onset ADS High craving Impulsive behaviour Wants to be social drinker Naltrexone- Checklist Normal LFT No opioid use Avoid in pain syndromes Adverse effects- Sexual Long acting injections 21
- 22. Acamprosate Indications Late onset ADS Protracted withdrawal Deranged LFT Multiple medical co morbidities Can be started along with detoxification Can be taken along with alcohol Contraindications B/l renal artery stenosis 22
- 23. Combination Naltrexone + Acamprosate More effective than placebo and Acamprosate alone Not effective than Naltrexone alone due to tackling of both “reward” and “relief” Acamprosate + Disulfiram Improves effectiveness of Acamprosate 23
- 24. Topiramate Both early and late onset ADS Comorbid seizure/migraine/obesity Adverse effects Naming/ word finding difficulties Worsen neuropathy/psychosis Contraindications Glaucoma/urolithiasis/Malnourished 24
- 25. Baclofen High craving Presence of significant liver damage Harm reduction strategy S/e- excessive sedation, constipation, allergic reaction, muscle weakness Contraindication- Seizure disorder 25
- 26. SSRI Late onset ADS Co morbid depression/ anxiety Can worsen early onset ADS Combination with anticraving agent- more effective Worsen outcome in early onset, family history 26
- 27. Other medications Nalamfene Gabapentine Pregabaline Ondansetrone Antipsychotics TCAs 27 D Basu, PK Dalal, Clinical practice guidelines for the assessment and management of Substance use disorders, Indian Psychiatric society
- 28. Co-morbid illness Treat primary illness first Depression- Anticraving+ Antidepressants Anxiety- Anticrving+Buspirone BPAD- Mood stabilizers+ Naltrexone/ Acamprosate/Disulfiram Schizophrenia-Antipsychotics+ Anticraving 28
- 29. Psychotherapy 29
- 30. Motivation level Prochaska and DiClemente’s Wheel of Change 30 5 A’s-Ask, advise, assess, assist, arrange 5 R’s- Relevance, risk, rewards, roadblocks, repetition
- 31. Cognitive behavioural approaches Based on social learning model Craving associated with classical conditioning processes Reinforcing aspects of drugs associated with operant conditioning, modelling Trigger awareness and management HALTS – Hungry, Angry, Lonely, Tired, Serious Emphasis on skills training 31
- 32. Cognitive behavioural approaches contd. Contingency management/behavioural contract Community reinforcement Assertion training Cue exposure treatment Covert sensitization Aversion therapy 32 THE BASICS OF ADDICTION COUNSELING: DESK REFERENCE AND STUDY GUIDE, Tenth Edition - June 2009 NAADAC, the Association for Addiction Professionals
- 34. Relapse prevention Identify their high- risk relapse factors and develop strategies to deal with them Understand and deal with social pressures to use substances Develop methods of coping with negative emotional states Learn methods to cope with cognitive distortions Develop and enhance a supportive social network Develop a plan to manage a lapse or relapse 34 Mary E. Larimer, Ph.D., Rebekka S. Palmer, and G. Alan Marlatt, Ph.D. An Overview of Marlatt’ s Cognitive- Behavioral Model, Relapse Prevention, Alcohol Research & Health,1999
- 35. Brief therapy An approach to therapy that includes a shorter time period and fewer sessions than “traditional” therapy MAIN PRINCIPLES Induction Phase Alliance (pretreatment) Refocus/Change Termination/Homework Continuation/Follow-up 35
- 36. FRAMES Model Hester and Miller Feedback Responsibility Advice Menu of options Empathy Self-efficacy 36 Hester RK, Miller WR. Handbook of Alcoholism Treatment Approaches. 2 ed. Boston, MA: 1995
- 37. MOTIVATIONAL ENHANCEMENT THERAPY (MET ) Client centred Enhancing intrinsic motivation Exploring and resolving ambivalence about a particular change Principle of motivational psychology Either outpatient or inpatient To mobilize the client’s own resources 37 THE BASICS OF ADDICTION COUNSELING: DESK REFERENCE AND STUDY GUIDE,Tenth Edition - June 2009 NAADAC, the Association for Addiction Professionals
- 38. MET Contd. Principles of MET: “EARS” Express Empathy Amplify Ambivalence ; Avoid Argument Roll with Resistance Support Self-efficacy 3 Phases Building motivation for change Strengthening commitment to change Follow through strategies 4 sessions 38 THE BASICS OF ADDICTION COUNSELING: DESK REFERENCE AND STUDY GUIDE Tenth Edition - June 2009 NAADAC, the Association for Addiction Professionals
- 39. Group therapy Members can be 8-12 Sessions- 6-12 Objectives increasing self esteem increasing motivation for abstinence developing a degree of insight into each person’s behaviour and attitudes Principles Universality Altruism Instillation of hope Imparting information Corrective recapitulation of primary family experience Social skills training Imitative behaviour Cohesiveness Existential factors Catharsis Interpersonal learning Self-understanding 39
- 40. Family Intervention To maintain the abstinence behaviour To deal with codependency To enhance the social support system of the family To manage the psychosocial disturbances in the significant others of the individual 40
- 41. Network therapy This is an approach with predominantly loss of control and frequent relapses Cognitive behavioural approach to relapse prevention Support of the patient’s natural social network Orchestration of resources to provide community reinforcement 41
- 42. Self help groups Alcoholic Anonymous and related groups Big book- Alcoholics Anonymous: The Story of How More Than One Hundred Men Have Recovered from Alcoholism 12 traditions- guidelines for group governance 12 steps – admitting to be overpowered by alcohol, belief in higher power Meetings- closed or open 42
- 43. References Benjamin James Sadock, Virginia Alcott Sadock, Pedro Ruiz. Comprehensive Textbook of Psychiatry. 9th ed. Philadelphia: Lippncott Williams & Wilkins. Benjamin James Sadock, Virginia Alcott Sadock. Synopsis of Psychiatry. 11th ed. Philadelphia: Lippncott Williams & Wilkins David T. The Maudsley Prescribing Guidelines in Psychiatry, 12th ed Stephen M Stahl, Stahl’s Essential Psychopharmacology, 4th ed 43
- 44. Thank You 44
Editor's Notes
- and this is given as a 10% soln. in 5% Dextrose (A loading dose of 0.6g/kg should be given followed by IV infusion of 0.07g/kg/hr for non-drinkers and 0.16g/kg/hr for regular drinkers