ALCOHOL USE DISORDER - 2

ManagementDr. Priyal Desai

TREATMENT Treatment for alcohol use disorder includes the following :

Intervention Detoxification Relapse prevention

INTERVENTION Intervention is a process aimed at increasing motivation to as

high a level as possible regarding treatment and continued abstinence. A discussion of their presenting complaint can be a useful way to show empathy and enhance motivation to change.

If the patient does not respond the first time, similar interviews can be continued with a non-judgemental approach.

Persistent and good interpersonal relations help getting good results.

STAGES OF MOTIVATION Pre-contemplation Contemplation Preparation Action Maintainance Termination

MOTIVATIONAL INTERVIEW Develop an understanding regarding the consequences

regarding the ill effects of alcohol. Explaining the benefits of changing the behaviour. Recognition of ambivalence of the patient towards abstinence . Show sensitivity towards the readiness of the patient to

change. Resistance can be managed by discussions and and problem

solving rather than criticism and confrontation. Exercise: ask the patient to keep a book for noting the events

between visits for which relapse occurred or could have occurred.

BRIEF INTERVENTIONS- FRAMES

Developed by Miller and Sanchez F= Feedback R=Responsibility A=Advice M=Menu E= Empathy S= Self-efficacy

EXTENSIVE INTERVENTIONS

Engaging- establishing a helpful connection and working relationship

Focusing- Developing and maintaining specific direction in the conversation about change

Evoking- elicitng the patients motive about change Planning- Developing commitment to change and

forming a specific action plan to change

QUESTIONNAIRES FOR ALCOHOL USE DISORDER

OTHERS MAST (Michigan alcohol screening test) SASQ (single alcohol screening question) CRAFFT ( Car, Relax, Alone, Forgot, Friends and family,

trouble)

FAMILIAL HELP The family can be of great help in the intervention and subsequent

treatment. Relatives and friends need to learn to not protect the patient from the

problems caused by alcohol. Families can take help of support groups like AA. Those support groups help family members and friends see that they

are not alone in their fears, worry, and feelings of guilt. Members share coping strategies and help each otherfind community

resources. The groups can be useful in helping family members rebuild their lives,

even if the alcoholic person refuses to seek help.

DETOXIFICATION There are 2 main steps in the process of detoxification:-Thorough physical examination- Rest and supplementation of depleted nutrients of the body• Majority people with alcohol dependence experience mild to

moderate levels of withdrawal.• Total alcoholics in India : 4 crores• Total number of government registered beds for detoxification: 5000

MILD OR MODERATE WITHDRAWAL Alcohol withdrawal develops because the brain has adapted to the presence

of a brain depressant and cannot function adequately in the absence of the drug.

Treatment can focus on giving enough of a brain depressant on the first day to diminish symptoms and then weaning the patient off the drug over the next 5 days to both diminish symptoms and minimize the possibility of a severe withdrawal.

Any depressant, including barbiturates or a benzodiazepine, either short-acting drugs, such as lorazepam or long acting like chlordiazepoxide and diazepam.

When taking a short-acting drug, such as lorazepam, the patient must not miss any dose because rapid changes in blood benzodiazepine concentrations may precipitate a severe withdrawal.

Others can also include newer anti convulsants like gabapentin.

SEVERE WITHDRAWAL For the less than 1 percent of alcoholic patients with extreme

autonomic dysfunction, agitation, and confusion—that is, also called delirium tremens—there is no perfect treatment.

The withdrawal symptoms can then be minimized either through the use of benzodiazipines or through antipsychotic agents such as haloperidol.

PROTRACTED WITHDRAWAL

Symptoms of anxiety, insomnia, and mild autonomic overactivity are likely to continue for 2 to 6 months after the acute withdrawal has disappeared Although no pharmacological treatment for this syndrome appears

appropriate, it is possible that some medications for the rehabilitation phase, especially acamprosate, may work by diminishing some of these symptoms.

Cognitive and behaviour therapies help in relieving these symptoms.

REHABILITATIONThe process of rehabilitation has the following concepts: (1) continued efforts to increase and maintain high levels of motivation for

abstinence; (2) work to help the patient re-adjust to a lifestyle free of alcohol (3) relapse prevention.

COUNSELLING Counselling efforts in the first several months should focus on day-to- day

life issues to help patients maintain a high level of motivation for abstinence and to enhance their functioning.

To optimise motivation, treatment sessions should explore the consequences of drinking, the likely future course of alcohol-related life problems, and the marked improvement that can be expected with abstinence

. Whether in an inpatient or an outpatient setting, individual or group counselling is usually offered a minimum of three times a week for the first 2 to 4 weeks, followed by less intense efforts, perhaps once a week, for the subsequent 3 to 6 months.

Much time in counselling deals with how to build a lifestyle free of alcohol.

RELAPSE :

High risk situations: negative emotional states

Positive emotional statesSocial gatherings/ occasionsSocial/ peer pressureAbstinent violation effect

RELAPSE SETUPS A series of covert decisions or choices, seeming inconsequential but

set up the person for high risk of relapse. AIDs- apparently irrelevant decisions Lifestyle factors Urge and cravings; Urge: sudden impulse to engage in an act without thinking about

the consequences like alcohol consumption Cravings: subjective desire to experience the effects or

consequences of an act like alcohol consumption

RELAPSE

http://pubs.niaaa.nih.gov/publications/arh23-2/151-160.pdf

RELAPSE PREVENTION Intervention strategies: variety of cognitive and behavioral approaches

that can lead to prevention of relapse. Specific intervention strategies: -identifying and coping with high risk situations -enhancing self efficacy -elimination of myths and placebo effect -lapse management -Cognitive restructuring

RELAPSE PREVENTION (CONTD.) Global lifestyle self control strategies Balanced life and positive addiction Stimulus control techniques Urge management techniques Relapse road maps

PHARMACOLOGICAL INTERVENTION- DISULFIRAM

Action: inhibits alcohol metabolism and building the levels of aldehyde in the body leading to reactions

Contraindication: use of alcohol Adverse reactions: flushing ,headache, nausea, sweating , tachycardia Serious adverse effects: hepatitis, optic neuritis, peripheral neuropathy,

psychosis Dose: 125-500 mg daily in adults for 6 to 8 months Precautions: noṭ to take it till 12 hrs after alcohol consumption Alcohol induced disulfiram reaction can occur unto 2 weeks after alcohol

NALTREXONE Action: blocks opioid receptors and reduces craving and reduces

reward in drinking Prevents relapse of heavy drinking Contraindication: opioids, acute hepatitis and renal failure Adverse reactions: nausea , vomiting headache , anxiety, fatigue

dizziness, constipation, Dose: 50-150 mg daily orally for 6 to 8 months

380mg IM once a month Precautions: consider urine toxicology monitoring to rule out current

use of opioids Monitor LFT

ACAMPROSATE Action:blocks GABA AND glutamate neurotransmitter Promotes abstinence Contraindication: acute renal impairments Adverse effects: anxiety, depression, diarrhoea , flatulence, nausea,

abdominal pain, headache, somnolence, decreased libido, amnesia, confusion

Dose:333 mg thrice a day to 666mg thrice daily

ALCOHOLICS ANONYMOUS Alcoholics Anonymous (AA) is an international mutual aids fellowship

founded in 1935 , by Bill Wilson and Dr. Bob Smith in Akron, Ohio. AA stated "primary purpose" is to help alcoholics "stay sober and help

other alcoholics achieve sobriety". With other early members Bill Wilson and Bob Smith developed

AA's Twelve Step program of spiritual and character development. It is estimated that there are over 115,000 groups and over 2,000,000

members in approximately 170 countries. It has its head offices in various cities of India like Delhi, Mumbai, Kolkatta,

Tiruvnanthpuram. In Gujarat, the head office is at Surat.

ALCOHOLICS ANONYMOUS-12 STEPS We admitted we were powerless over alcohol—that our lives had become

unmanageable. Came to believe that a Power greater than ourselves could restore us to

sanity. Made a decision to turn our will and our lives over to the care of God as

we understood Him. Made a searching and fearless moral inventory of ourselves. Admitted to God, to ourselves, and to another human being the exact

nature of our wrongs. Were entirely ready to have God remove all these defects of character

ALCOHOLICS ANONYMOUS-12 STEPS Humbly asked Him to remove our shortcomings. Made a list of all persons we had harmed, and became willing to

make amends to them all. Made direct amends to such people wherever possible, except when to do so

would injure them or others. Continued to take personal inventory, and when we were wrong, promptly

admitted it. Sought through prayer and meditation to improve our conscious contact with

God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.

Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.

Thank you