Alcohol Dependence
Presentation:
- First quantify amount of alcohol in g/d (10g = 1 standard drink), then type of alcohol, then pattern of alcohol use
- Ask if drink alone, or with others. If they drink with others then this may be an area of intervention that you could target
- Ask about family history of alcoholism as there is a genetic component
- CAGE questions to assess severity of alcohol dependence
- Have you thought of Cutting down
- Do you feel Annoyed when others criticise your drinking
- Have you felt Guilty about your habit
- Do you need an Eye opener in the morning to settle your nerves
- Two affirmative responses are 77 percent sensitive and 79 percent specific for alcohol abuse and dependence, but only 53 percent and 70 percent, respectively, for unhealthy alcohol use
- Impact of alcohol use on activities of daily living
- sick days, financial dependence, incarcerations, driving under the influence and other risky behaviours
- Alcohol dependency is frequently present as a dual diagnosis and with other substance use
- Physical complications (multi system)
- Heart failure symptoms
- peripheral neuropathy
- Wernicke - Karsakoff syndrome
- Alcohol withdrawal symptoms
- History of withdrawal seizures
- History of treatment
- non-pharmacological versus pharmacological treatment
- Biological - family history, other substances of abuse
- Psychological - history of other mental health ailments
- Social - isolation, other drinking partners, poverty
- Previous failed attempts
- Blood EtOH level for recent consumption
- Tests for chronic consumption
- GGT
- AST> ALT
- Macrocytic anaemia with MCV >100
- Carbohydrate Deficient Transferrin (CDT)
- GGT is the most sensitive, CDT has a similar sensitivity but higher specificity
- CT Brain in karsakoff dementia - rule out other causes
- According to the National Health and Medical Research Council (NHMRC) guidelines, average daily consumption of alcohol in excess of two standard drinks is a health risk for men and women
- In any one day you should not exceed > 40g EtOH
- Significant dependence associated with a withdrawal syndrome on cessation is more likely in those whose regular consumption is greater than eight standard drinks per day, and is increased if they also use other sedatives. - eTG 2016
- Harm reduction
- Always give 100mg thiamine daily to prevent development of Wernicke-korsakoff secondary to vitamin B1 deficiency
- Minimise harm and risk taking activities by providing safe transport from pubs, making sure patient is on disability service pension to minimise participation in criminal activities etc
- Brief interventions
- FLAGS
- Feedback – provide feedback on the impacts
- Listen – to their concerns
- Advice – on the benefits of quitting
- Goals
- Strategies
- FLAGS
- Detox/ withdrawal management
- Two options, can be done as in-patient if there is high risk of seizures, or outpatient
- Use benzodiazepines to reduce withdrawal symptoms and prevent seizures
- Guided by the alcohol withdrawal scale
- Regular diazepam, oxazepam if there is liver dysfunction
- eTG 2016 --> diazepam 20mg q2h max dose 60mg daily for withdrawal symptoms
- Treat likely vitamin B1 deficiency:
- Thiamine 300mg TDS IV/IM for 5 - 7 days then 300mg daily thereafter
- Relapse prevention
- Non-pharmacological:
- Link-up patient with support groups focused on relapse prevention such as alcoholics anonymous
- Counselling
- Cognitive Behaviour therapy such as the SMART recovery
- Residential rehabilitation
- Pharmacological (Aust Prescr 2015;38:41-3 ) - really only two PBS approved treatments. Other's such as disulfiram, baclofen, topiramate exist but are not approved
- Acamprosate - safe in liver disease, shown to be effective in maintaining abstinence
- synthetic GABA analogue
- larger pill burden therefore may decrease compliance
- no interactions with opioids compared to naltrexone
- Less SE compared to naltrexone
- contraindicated in pregnancy
- Naltrexone
- orally acting mu opioid receptor antagonist
- PBS approved, case reports of hepatotoxicity
- slightly larger effect size than acamprosate
- once daily dosing therefore helps with compliance
- Cant use with opioid pain medications due to its competitive antagonism
- Naltrexone is contraindicated in acute hepatitis or liver failure, and liver function should be monitored
- more adverse effects including headache, nausea, lethargy and dysphoria. These effects are usually transient and rarely lead to cessation of therapy.
- Acamprosate - safe in liver disease, shown to be effective in maintaining abstinence
- Non-pharmacological:
- Biological
- Dilated cardiomyopathy
- Peripheral neuropathy
- dupytrens contracture
- Parotid enargement
- Wernicke's encephalitis
- Korsakoff's dementia
- Alcoholic hepatitis +/- cirrhosis
- bone marrow supression
- Myopathy
- Psychological
- Many have con-comitant dual diagnosis such as anxiety, depression
- Social
Nicotine dependence
BMJ 2016;352:i571
History
History
- Smoking history - quantify in terms of pack years, current cigs/d, pattern of use (day/ night/ social)
- Previous attempts at cessation: (1) withdrawal sx (2) reason for failing (3) Medications/ interventions
- Assess level of dependence. High dependence behaviours include waking at night to smoke, smoking within first 5 mins after waking, smoking > 30 ciggs/ d
- Use a "motivational interviewing" technique
- Brief medical intervention using the FLAGS approach
- Feedback, Listen, Advice Goals, Strategies
- Inform of the benefits: financial, health
- Aim to set a quit date
- Enlist the support of family and friends
- Explore reasons why previous attempts failed
- Warn patient of potential AEs of quitting (short lived)
- Relapse – 50% in 1st wk, less after 2nd wk, Weight gain, Depression, Irritability
- Regular follow up: 1 week after quitting (highest relapse rate in first 2 weeks), Regular follow up thereafter - This should be done with the general practitioner
- Refer to QUITLINE (13 QUIT) +/- smoking cessation clinic
- Offer written information packs
- Dealing with and predicting a plan if relapses
- Realising and making a plan to deal with triggers of smoking (workmates, friends), dealing with craving
- Barriers: EtOH, Stress, Exposure (friends, social situation), Caffeine, fixed health beliefs
- Ineffective Strategies --> Smoking less cigarettes, Smoking low tar/nicotine cigarettes, Acupuncture: no evidence, Hypnotherapy: no evidence – anecdotal evidence
- Relative risks of abstinence are 1.60 (95% confidence interval 1.53 to 1.68) for NRT, 1.62 (1.49 to 1.76) for bupropion, and 2.27 (2.02 to 2.55) for varenicline.
- Nicotine Replacement Therapy (NRT)
- delivers nicotine at a lower concentration and more slowly than do cigarettes
- Doubles quit rate
- S/E: chest pain, irritation at the delivery site.
- Types: Patches, Gum, inhaler, lozenges (all equal)
- Contraindications: Recent MI, Severe arrhythmias, recent CV event
- Patches
- Mod-high dependence: 21mg / 24 hrs
- Low-mod: 14mg / 24 hrs
- Aim to stop after 12 weeks
- Combination therapy
- Higher abstinence rates with combination Rx in patients who continue to experience withdrawal symptoms using only one type of NRT
- NRT Gum: 2mg PRN
- Varenicline (Champix)
- Partial agonist at nicotine receptor --> reduced withdrawal symptoms and pleasurable effects of smoking
- More effective than buproprion and NRT
- SEs: Nausea and abnormal dreams
- A Cochrane review found no significant differences in neuropsychiatric events (0.15% v 0.21%) or cardiac events (0.6% v 0.5%) in trials comparing varenicline with placebo
- Precaution: Renal failure and cardiac disease
- Can still smoke, don’t combine with NRT (it’s a partial agonist)
- Contraindications:
- Epilepsy
- Psych illness/suicidality
- Pregnancy/lactation
- PBS: Patient must have ceased smoking in the process of completing an initial 12-weeks or ceased smoking following an initial 12-weeks of PBS-subsidised treatment with this drug in the current course of treatment.
- Bupropion (Zyban)
- Noradrenaline and dopamine reuptake inhibitor (initially designed as an antidepressant)
- Commenced while still smoking
- Takes 1 week for steady state concentrations
- Contraindications:
- Epilepsy (seizure risk dose dependent)
- CNS tumour
- Bulimia or Anorexia Nervosa
- Withdrawal from alcohol of benzodiazepines
- SEs: Insomnia, HTN, seizures
- Nortryptiline 25mg daily titrating up to 75 mg daily
- Second line agent
- Start 10-28 days before quitting
- Electronic cigarettes and other electronic nicotine delivery devices
- Not available for sale in Australia.
- A Cochrane review showed weak evidence that electronic cigarettes containing nicotine were more effective for helping people to quit smoking than those without nicotine BUT the harms from vapour are yet unknown
- Not available for sale in Australia.
Depression
History
- Major Depression – 5 symptoms (must incl 1 major), must be present for 2 months and must be impacting on activities of daily living
- Mnemonic: A SAD FACES: Anhedonia, Sleep disturbances, Appetite, Dysphoria, Fatigue, Agitation/ retardation, Concentration difficulties, Esteem/ guilt, Suicidality
- Major Symptoms: Anhedonia, Low mood
- Screen for medical causes: eg symptoms of hypothyroidism
- ALWAYS assess or suicide risk and risk of harm to others
- Risk factors:
- Older age
- Recent child birth
- Stress
- Coexisting medical conditions
- Stroke, DM, Cancer, post MI, post CAGS***, obesity
- Family history, trauma history
- Female
- Drugs – alcohol, corticosteroids, propranolol, interferon, illicit drugs
- Protective factors:
- Family supports
- Employment
- secure housing
- Differentials
- Dysthymia – often fluctuant low mood of at least 2y duration though insufficient sx for major depression
- Adjustment disorder/ Reactive depression: period of stress and emotional disturbance which interferes w social functioning and often follows a life event.
- Anxiety
- A – Appearance – eg dishevelled
- B – behaviour
- C – Character of speech
- M – mood, ask them to describe their mood
- A – affect, ?congruous with the way they describe mood
- S – risk of self harm/ SI
- P – features of psychosis – thought disorder/ hallucinations/ delusions
- Bloods: (exclude organic causes)
- FBC – anaemia
- TFTs – hypothyroidism
- Ca
- B12/Folate
- LFTs
- CT – brain
- Multidisciplinary and multimodal approach
- Non-pharmacological
- Exercise and healthy diet
- Lifeline contact
- Peer/ support groups – if chronic illness
- Education and support for family and friends – i.e. engage supports
- Resources: lifeline, black dog institute, beyond blue
- Psychological
- Counseling – structured problem solving and stress management
- CBT – medicare subsides 10 sessions with a psychologist
- Key principles – Aims to identify, challenge and modify maladaptive, automatic or core thoughts/ perceptions and behaviours
- Family therapy
- Websites: CBT through MoodGYM Training program
- Referral to psychiatrist
- Pharmacological
- For moderate - severe depression use a combination of psychological and pharmacological therapies
- SSRIs - citalopram, fluoxetine, paroxetine, escitalopram, setraline
- Nausea, anxiety, diarrhoea, constipation, headache insomnia, sexual dysfunction (loss of libido, anorgasmia)
- SIADH, bone mineral density impairment, impaitred haemostasis, Lowered seizure threshold
- SNRIs – venlafaxine, duloxetine, desvenlafaxine
- Nausea, vomiting, anorexia, rash, dizziness
- Periodic limb movements of sleep
- Sexual dysfunction
- Hypotension, hyponatraemia
- Mirtazepine
- MOA: analogue of mianserin
- Good for sleep, and appetite stimulation
- Sedation more likely at lower doses <15mg
- Weight gain
- TCA – amitryptiline, dothiepin, doxepine
- Anticholinergic SE
- Long QRS, lowered seizure threshold
- ECT – good for refractory sx