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 alcoholDon’t pursue topic

2. Would like to change but not just yetGive written information about how to seek help

3. Wants to change nowUse motivational interviewing technique to start change

4. Already started to changeReinforce 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 patientsRecognition of harm causedDesire to changeFeasibility 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;330:139-141

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 200-300mg 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 relapsecan 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