2007

Identification  CAGE questionnaire  Have you ever thought that you should Cut down on your drinking  Has anyone Annoyed you by commenting on the amount you drink  Have you ever felt Guilty about the amount you drink  Do you ever have an Eye opener

Cycle of change 1. Anger at mentioning alcohol Don’t pursue topic 2. Would like to change but not just yet Give written information about how to seek help 3. Wants to change now Use motivational interviewing technique to start change 4. Already started to change Reinforce and support change

Barriers to change  These need to be identified

Motivational interviewing  People believe what they hear themselves say  Empathic interviewing style  Open ended questions  Reflective listening  Get on their wavelength  Feedback about risk  Agree factual information about personal harm or impairment  Balance sheet of pro’s and cons of changing /not changing

Motivational interviewing  People believe what they hear themselves say  Roll with resistance  Avoid confrontation  Arguments about terms such as alcoholic are fruitless particularly in the early stages  Support self efficacy  Patient takes responsibility for achieving goals  Choosing from menu of options  Encourage belief that change is possible

Motivational interviewing  People believe what they hear themselves say  Reinforce self motivate patients  Recognition of harm caused  Desire to change  Feasibility of change

Withdrawal symptoms  Common features on stopping alcohol  Anxiety and agitation  Tachycardia  Sweating  Tremor of extended hands, tongue or eyelids  Nausea and vomiting  Insomnia  Withdrawal fits  Confusion  hallucinations

Withdrawal symptoms  Should be mild if  Alcohol free at consultation  Male drinking < 15units/day  Female drinking < 10 units/day  Units of Alcohol  1 ordinary glass of wine 9/bottle  ½ pint low strength beer  1 standard pub short

Withdrawal symptoms  Management – mild symptoms  Rest  Relaxation  Reassurance that they will pass in a few days  Explanation – they are evidence of that the brain has adapted to living in an alcoholic environment and will take time to readjust to one that is alcohol free

Withdrawal symptoms  Need for specialist or hospital referral  Confusion  Hallucinations  History of fits or epilepsy  Risk of suicide  Failed home detox  Poor nutrition  Unsupportive home environment  Acute physical or psychiatric illness  Any symptoms of encepalopathy

Wernicke’s encepalopathy  Signs  Confusion  Ataxia  Opthalmoplegia  Nystagmus  Coma  Hypotension  Hypothermia  Any unexplained neuro signs during withdrawal

Wernicke’s encepalopathy  Require urgent specialist assessment  Urgent treatment with parentral thiamine (Pabrinex IM )

Drug treatment  Drug of choice for withdrawal are benzodiazepines  Can induce temporary problems with cognition and recall  Are addictive if taken over time  Detox with benzos should not be continued for more than 7 days  Start with high dose chlordiazepoxide 120mg/day or diazepam 20mg/day

Copyright ©2005 BMJ Publishing Group Ltd. Ritson, B. BMJ 2005;330: Detoxification regimen

Other support  Patients and family should be advised  To stay off work  Not drive  Rest  Drink plenty of fluids – fruit juice rather than stimulants such as cafeine  Abstain from alcohol

Other support  Community nurse of GP should visit daily to  Monitor progress  Review drugs  Assess mental state and vital signs  Breathalyse for alcohol if possible  Patient may think they can now handle alcohol must make it clear that drinking must not be resumed

Daily check  Tremor  Pulse  Temperature  Blood pressure  Level of consciousness  Orientation  Dehydration

Vitamins  If well nourished with moderate alcohol dependence no vitamins required  If under nourished or frequent relapse or self neglect  Then mg thiamine a day for 2-3 months will help minimise risk to brain and peripheral nervous system  May need parental admin during early stages of detox

Preventing relapse  Triggers to relapse  Environment  Availability  Pub atmosphere  Custom  Always drinks at certain times, occasions and situations  Interpersonal  Stress  conflicts

Preventing relapse  Triggers  Intrapsychic  Expectations  Anxiety  Social phobias  Depression or elation  Overconfidence  Feeling good  I have got over my drinking problem  I can take some alcohol again

Preventing relapse  Drinking diary  Balance sheet of good and bad consequences of continued drinking  Patient should set own goals  Monitor progress  Identify ways of dealing with triggers to relapse

Preventing relapse  Pharmacotherapy  Disulfiram  Blocks metabolism of alcohol flooding the body with toxic acetaldehyde which causes flushing, palpitations, nausea, faintness and even collapse  Start with 200mg/day can be increased to 400mg  Contra indicated with liver disease, cardiovascular disorders, pregnant women, suicidal patients or those who are cognitively impaired  Only effective if use is supervised

Preventing relapse  Pharmacotherapy  Acamprosate  Helpful adjunct to psychological therapies.  Start as soon as abstinence is achieved  Can be continued during relapse  can be continued for 1 year

Preventing relapse  Drug treatments should always be accompanied by psychological support and therapy aimed at attaining a longer term change of lifestyle that is drug free