Alcohol Prescribing

1. Alcohol Prescribing Dr Kostas Agath, EMBA(dis), FRCPsych Medical Director, Addaction Warwickshire Shared Care Conference, Staverton Park, 22 March 2012 k.agath@addaction.org.uk

2. Objectives • To place detoxification in the wider treatment context • To provide a ‘how-to-do-it’ overview • To tackle the most common problems a clinician faces k.agath@addaction.org.uk

3. Vignette - A • John Smith is a 35 year old man with alcohol dependence for 10 years. • He wants to detoxify from alcohol • How would you proceed? k.agath@addaction.org.uk

4. Detoxification = Treatment: Discuss • Detoxification is NOT a treatment in its own right: • It does NOT reduce the likelihood of a future detoxification • Within 6 months, almost 50% relapse -irrespective of the substance of dependence k.agath@addaction.org.uk

5. The Cycle of Behavioural Change (Prochaska and Di Clemente, 1986) • The cycle has five stages: • Pre-contemplation • Contemplation • Preparation • Action • Maintenance • Potential exit from any stage through relapse • Important to match the ‘stage’ the client is in with the appropriate intervention k.agath@addaction.org.uk

6. Applying the cycle to ‘detox’… • Pre-contemplation • Client not aware of substance misuse (SM) problems • Client has no intention to detoxify • Contemplation • Client ambivalent about dealing with SM problems • Detox, if anything, only a fleeting thought • Preparation • Client accepts need to change • Seriously considers undergoing detox • Asks info about detox • Action • Detox takes place • Affective, Cognitive and Behavioural Components also amenable to change • Maintenance • Relapse prevention (psychological & pharmacological) to strengthen sobriety k.agath@addaction.org.uk

7. What if there is a relapse? • Relapse • Client steps back in a previous stage of the cycle, and…. • Should be considered re-starting a new cycle.. • ..up to and including the preparation cycle (i.e. NOT ‘action stage’ – action without preparation is associated with poor outcome),and…. • ..lessons from the previous cycle should be incorporated in the treatment plan of the new cycle k.agath@addaction.org.uk

8. Vignette - B • John Smith is a 35 year old man with alcohol dependence for 10 years. • He drinks 1 litre bottle of whisky daily • He wants to detoxify from alcohol • He weighs more than 60Kgrs (~9.45 stones) • You have established that he is well prepared for a detoxification • How would you proceed? k.agath@addaction.org.uk

9. Alcohol Detoxification • What agent & what regime should one use? • Should one use Vitamin Supplementation? • Should one use pharmacological means of Relapse Prevention? k.agath@addaction.org.uk

10. 1a. What Agent? • Benzodialepines • Chlordiazepoxide • Carbamazepine • Withdrawal Seizure Prevention? • Do NOT use Chlormethiazole • Causes Respiratory Depression k.agath@addaction.org.uk

11. 1b. What Regime? • Fixed-Schedule Tapering • Variable dose – titrated against CIWA-Ar (Clinical Institute Withdrawal Assessment Alcohol revised scale) • Front Loading • Benzo every 60-90 min until light sedation • Then, NO further benzos are given k.agath@addaction.org.uk

12. k.agath@addaction.org.uk

13. 2. Is Vitamin Supplementation Necessary? • Yes!! • Preferably IV (orally: poor availability) • but: risk of anaphylaxis → need of resuscitation facilities • “Higher risk= higher dosage for longer” • Regimes (SIGN 2003, Royal College of Physicians 2001) • Thiamine 50mg bd - 200mg qds for 3/52 to lifetime if deficient diet/ persisting cognitive impairment • Vit B co strong 30mg/d until no concerns about client’ diet • 1-2 pairs Pabrinex (Vit B+C) IM/IVfor 3/7 to 5/7 or until clinical improvement seizes k.agath@addaction.org.uk

14. 3. Pharmacological Means of RP • Adjunct to psychosocial treatments • 1. Disulfiram • ↓ number of drinking days • Better (but not always significant) outcome if supervised • Implants not demonstrated to be effective (? low bioavailability) • 2. Acamprosate • ↑ abstinence (length and rate) • Effect lasts after treatment is stopped • Doubtful effect if not initiated quickly after detox • Adding naltrexone = ↑ outcome k.agath@addaction.org.uk

15. /continued from previous slide/ • 3. Naltrexone • ↑ abstinence rates in short-term treatment • Deters progression from a lapse to relapse • Similar efficacy to Acamprosate, Disulfiram • Adding acamprosate: No effect on outcome • 4. SSRIs • Not effective for alcohol dependence • In depression, SSRIs could improve mood (but not drinking outcome) when treating alcohol dependence. k.agath@addaction.org.uk

16. Vignette - C • John Smith is a 35 year old alcohol dependent man who you successfully detoxified from alcohol 2 weeks ago. • He is on Acamprosate 666mg tds • He complains of insomnia and requests sleeping tablets for a week • How would you proceed? k.agath@addaction.org.uk

17. Sleep Hygiene • Individual sleep pattern self-correcting but needs time • Almost all drugs that cross the Blood-Brain Barrier undermine the sleep architecture • Post detox the psychological treatment better than pharmacological treatment of insomnia • Sleep hygiene the optimal approach • (keeping a sleep diary, fixing times for going to & getting out of bed, resisting dosing off at other times) k.agath@addaction.org.uk

18. Are withdrawal syndromes associated with death? • Yes (sedatives: alcohol, benzodiazepines, barbiturates) – mainly through Seizures • No (opioids) – but a quick titration might lead to an accidental Overdose k.agath@addaction.org.uk

19. Summing Up • Detox without preparation is futile • The pharmacological means of detoxification and relapse prevention are under-used • Insomnia in dependence does NOT warrant pharmacological treatment • Withdrawal seizures can kill • Unsafe methadone titration can also kill k.agath@addaction.org.uk

20. References • Department of Health (England) and the devolved administrations (2007). Drug Misuse and Dependence: UK Guidelines on Clinical Management. London: Department of Health (England), the Scottish Government, Welsh Assembly Government and Northern Ireland Executive • Kenna GA, Agath K, Swift R. (2007) Pharmacotherapy of Alcohol Misuse, Dependence and Withdrawal. Chapter 14 in: Peter Tyrer and Kenneth R Silk (eds) Cambridge Textbook of Effective Treatments in Psychiatry, pp 289-313, Cambridge University Press. • Raistrick, D., Heather, N., Godfrey, C. (2006). Review of the effectiveness of treatment for alcohol problems. National Treatment Agency, London [www.nta.nhs.uk] • NICE (2007). Drug Misuse: Psychosocial Interventions. (www.nice.org.uk) k.agath@addaction.org.uk

21. Thank You k.agath@addaction.org.uk