1. BERNARD MMED YR 2

2. management HISTORY MSE PHYSICAL EXAMINATION LAB INVSETIGATION INTOXICATION WITHDRAWAL BIOPSYCOSOCIAL MODEL PROGNOSIS

3. Labs Labs (BAL, CBC, Chem 22, Mg, TSH, RPR, lipase, UDS, UA, pregnancy test) PPD CXR EKG Acetaminophen and salicilate level as indicated

4. Alcohol Intoxication 20-99mg/l loss of muscular coordination, change in behavior 100-199mg/l ataxia, mental impairment 200-299mg/l obvious intoxication, nausea and vomiting 300-399mg/l severe dysarthria and amnesia

5. Alcohol Intoxication cont. 400-600mg/l coma occurs 600-800mg/l decreased respirations and blood pressure, obtundation, often fatal Important to remember the role of tolerance in all these categories

6. Management of Alcohol Intoxication Cardiovascular and respiratory support to control blood pressure and maintain airway Intravenous fluids (dextrose) thiamine, Folate, VITAMIN B-12 Closely monitor until withdrawal begins and then start treatment

7. Monitoring Alcohol Withdrawal MSSA (Modified Selective Severity Assessment) CIWA-A (Clinical Institute Withdrawal Assessment for Alcohol) Advantage for personnel to monitor progress and treat accordingly

8. Withdrawal Signs and Symptoms Tremor Agitation Autonomic changes (BP, HR, Temp.) Seizures Sensorium changes (eg, hallucinations, confusion)

9. Withdrawal Syndrome Stage 1 Begins within 24 hours Lasts up to 5 days 90% of cases do not go beyond stage 1 Other symptoms include depressed mood, anxiety, diaphoresis, headache, nausea/vomiting, etc.

10. Withdrawal Syndrome Stage 2 Mostly untreated or undertreated in stage 1 Same signs and symptoms in stage 1 only more severe Hallmark is hallucinations Usually occurs 48 hours after last drink

11. Withdrawal Syndrome Stage 3 Usually occurs 72 hours after last drink Delirium Tremens (acute reversible organic psychosis) has 2% mortality Lacks insight into hallucination, often disoriented and labile Seen in persons with severe alcoholism and/or significant medical problems

12. Detoxification Treatment Begin benzodiazepine at onset of withdrawal symptoms Be cautious that symptoms are withdrawal and not intoxication.

13. Detox Pharmacology Benzodiazepine and Barbiturate equivalents: Diazepam 10mg Lorazepam 2mg Phenobarbital 30mg Chlordiazepoxide 25mg Oxazepam 30mg

14. Detox Pharmacotherapy Know 2-3 drugs well for routine detox (e.g., Diazepam 10-20 mg Q1 hr prn withdrawal) Magnesium sulfate 2 gm for severe withdrawal (esp. in seizure risk) Daily thiamine 100 mg x days folate 1mg o.d x 1 2-4weeks Supportive therapy (eg hypertension meds, etc.) Stage 3 withdrawal usually requires iv fluids, foley catheter, soft restraints, etc.

15. Alcohol Withdrawal Seizures More common in untreated alcoholics Should hospitalize if first seizure Need to be evaluated for other causes (eg, head injury, CVA, or CNS infection, etc.) if first seizure or history not clear Work up includes brain imaging and EEG 1 in 4 patients have a second seizure within 6-12 hours Must report any seizure to doctor and inform patient not to drive

16. Alcohol Withdrawal Seizures Mostly Grand mal seizures Usually 24-48 hours after last drink but may be within 8 hours BAC does not have to be zero Less than 3% become status epilepticus Increased risk if prior seizure or detoxing off sedative hypnotic as well

17. Alcohol Withdrawal Seizure Treatment Parenteral benzodiazepines (eg, ativan 2 mg or valium 10 mg iv stat) Seizure precautions Valium 10-20 mg q1 hour prn Anti-convulsants are generally not indicated unless the diagnosis is in doubt Work up if 1 st seizure

18. Pharmacotherapy Treatment Disulfiram Naltrexone Acamprosate

19. Disulfiram Deterrent therapy Inhibits metabolism of alcohol by blocking acetaldehyde dehydrogenase Acetaldehyde is toxic product causing the reaction (flushed, tachycardia, diaphoresis, nausea, headache, etc.) Metronidazole and alcohol may cause disulfiram like reaction

20. Disulfiram (cont.) Prescribing tips (read the label for alcohol if not sure) Monitor liver enzymes May cause psychosis Evaluate need for patient to take in front of staff NATREXONE Opiate blocker Evidence for reduced cravings and relapse rates 23% relapsed vs. 54% placebo during 12 week study

21. Acamprosate Affinity for GABA A and GABA B receptors Inhibits glutamate effect on NMDA receptors Multiple studies in Europe show it effectiveness and safety Tempesta, et al. (2000) found abstinence rate 57.9% with acamprosate versus 45.2% with placebo Sass, et al. (1996) found at the end of 48 weeks of treatment and 48 more weeks of follow-up that 39% of the acamprosate group vs. 17% of the placebo group remained abstinent

22. Motivation Is Central to Prevention and Intervention Motivational factors are central to understanding drug use. “People who stop drug use on their own without formal treatment, often referred to a choice or decision.” “Transtheoretical research points to a sequence of events or stages.” “Taking action also predicts change. “Positive reinforcement.

23. Drug Use Responds to Reinforcement “Preferred drugs are powerful reinforcers, chosen from among available options.” Drug use tends to be associated with a foreshorting of time perspective, so that longer term delayed rewards are discounted in value. Providing clear incentives for abstinence often yields rapid reductions in drug use.

24. There Are Identifiable and Modifiable Risk and Protective Factors for Problem Drug Use “Heredity contributes to risk for alcohol problems, and evidence is mounting for genetic predispositions for or against other drug use.” “Protective factors include. Nondrug positive reinforcement, stimulating environments, stress-buffering resources, close, high- quality positive relationships with nondrug involved people.

25. Stages of Change Model

26. Motivational Interviewing Motivational interviewing is an evidence-based intervention designed to enhance client motivation for change. Tested in a variety of clinical intervention modalities including brief 30-minute interventions, multiple sessions, ongoing counseling, and client assessment.

27. Stages of Change Model Precontemplation Stage- Individuals typically deny having a problem with drugs or alcohol and commonly resist change Therapeutic goal - Increase their consideration of the possibility that they have a problem while avoiding any attempt 2coerce the individual into accepting alcohol abuse label. Increase the individual's awareness that the behavior and its consequences may merit his/her attention and consideration.

28. Stages of Change Model Contemplation Stage Individuals begin to think about changing use of drugs/alcohol Commonly express ambivalence about changing their behavior. Benefit from a discussion of the pros and cons of changing their behavior. Referred to as a "decisional balance" discussion. Individual may be considering change, in this stage they have not committed to change.

29. Stages of Change Model Preparation/determination stage Individuals appear ready for and committed to action. Have decided to stop the problematic behavior and initiate positive behavior. Ambivalence about change may not be fully resolved in this stage. Commitment to change does not necessarily mean that change is automatic but instead requires action by the individual.

30. Stages of Change Model Action stage of change Individual is actively engaged in modifying the target behavior and their environment. Typically they have developed a plan for change with their social worker. Seeking support of family and friends facilitates success in this stage of change. Clients publicly stating their commitment to take action can solidify this effort. Typically requires three to six months, but the actual length will vary depending on the severity of the problem.

31. Stages of Change Model Maintenance phase Therapeutic focuses on maintaining the new behaviors. Behavioral patterns generally require time to emerge and stabilize. Clients may seek additional treatment for supporting recovery. Always the threat of relapse or return to the old problematic behavior.

32. Stages of Change Model Relapse or recycling stage of change Does not occur for all individuals, but relapse is very common in substance abuse in populations. People can regress from any stage to an earlier stage. Relapse may occur secondary to (1) Unexpected temptations, (2) May test their ability 2resist temptations of drugs or alcohol and fail. (3)Erosion of their sense of self-efficacy or commitment to change.

33. Motivation Enhancement Therapy (MET) (Miller, 2005) There are four key assumptions of MET (Miller, 2005). 1. Ambivalence about substance use is normal and constitutes an important motivational obstacle in recovery. 2. Ambivalence can be resolved by working with your client ’ s intrinsic motivations and values. 3.empathetic, supportive, yet direct, counseling style provides conditions 4change can occur.

34. Motivational Enhancement Therapy: A systematic intervention to evoke change in problem drinkers. Based on the principles of motivational psychology. Designed to produce rapid, internally motivated change. Does not attempt to guide and train the client, step by step, through recovery. Employs motivational strategies to mobilize the client’s own change resources. Miller, Chap. 5, Handbook of Alcoholism Treatment Approaches, 1995

35. Opening Strategies 1. Ask Open Questions 2. Listen Reflectively 3. Affirm – Compliments or statements of appreciation 4. Summarization –used to link together and reinforce material 5. Eliciting Self- Motivating Statements Recognizing disadvantages of the status quo (problem recognition) Recognizing advantages of change Expressing optimism about change Expressing intention to change

36. Motivation Enhancement Therapy Five Basic Principles of MET Express Empathy Develop Discrepancy Avoid Argumentation Roll with Resistance Arguing Interrupting Denying Ignoring Support Self-efficacy

37. Express Empathy Communications that imply a superior/inferior relationship are avoided. The therapist’s role is a blend of supportive companion and knowledgeable consultant. The client’s freedom of choice and self-direction is respected. Persuasion is gentle, subtle, always with the assumption that change is up to the client. Miller, Chap. 5, Handbook of Alcoholism Treatment Approaches, 1995

38. Avoid Argumentation: If handled poorly, raising of discrepancies can create defensiveness. The MET style explicitly avoids direct argumentation. No attempt is made to have the client accept or “admit” a diagnostic label. “The client, not the therapist voices the arguments for change.” “What makes you think that maybe you should do something about your drinking?” Miller, Chap. 5, Handbook of Alcoholism Treatment Approaches, 1995

39. Roll with Resistance: MET strategies do not meet resistance head on, but rather “roll with” the momentum, with a goal of shifting client perceptions in the process. New ways of thinking about the problem are invited, but not imposed. Ambivalence is viewed as normal, not pathological, and is explored openly. Solutions are usually evoked from the client rather than provided by the therapist.

40. Support Self-Efficacy: Self -efficacy - the belief that one can perform a particular behavior or accomplish a particular task. The person must believe he or she can change (Rogers & Mewborn, 1976). Optimism can also be found in the menu of different approaches available. A therapist’s own optimism may also powerfully influence client motivation and outcome. Leake and King (1977) demonstrated experimentally that therapist expectations of good prognosis are predictive of favorable outcomes among alcoholic clients. Miller, Chap. 5, Handbook of Alcoholism Treatment Approaches, 1995

41. Develop Discrepancy: Motivation for change occurs when people perceive a discrepancy between where they are and where they want to be. M.E.T. seeks to enhance and focus the client’s attention on such discrepancies. In certain cases (precontemplator), it may be necessary to 1 st develop such discrepancy by raising client’s awareness of the personal consequences of abuse. Miller, Chap. 5, Handbook of Alcoholism Treatment Approaches, 1995

42. Strong Evidence of Effectiveness Strong Evidence of Effectiveness (consistent support from controlled research) Patient-centered therapy Behavioral self control training Cognitive therapy Covert sensitization (a form of aversion therapy) Covert sensitization Oral and implant disulfiram (placebo effect has not been ruled out) Self-help manual Screening, Brief Intervention, Referral, and Treatment