ALCOHOL USE DISORDER

ALCOHOL USE IN INDIA 21% of adult males use alcohol (Ray et al, 2004)

5% women use alcohol (Benegal et al, 2005)

50% of all drinkers in India satisfy criteria for hazardous drinking

The typical pattern is heavy solitary drinking, involving predominantly

spirits and usually >6 standard drinks per occasion (Gaunekar et al, 2004)

Alcohol-related problems account for over a fifth of hospital admissions in India (Benegal, 2005)

Alcohol misuse has a disproportionately high association with liver disease, TB, HIV and suicidal acts (Benegal, 2005)

SCREENING INSTRUMENTS FOR ALCOHOL MISUSE

CAGEC – Have you been advised to Cut down?

A – Have you got Annoyed at other people asking you about your drinking?

G – Have you felt Guilty about your alcohol use?

E – Do you have an ‘Eye-opener’ – a drink in the morning?

SCREENING INSTRUMENTS FOR ALCOHOL MISUSE

AUDIT – alcohol use disorders identification test• How often do you have a drink containing alcohol?

• How many standard drinks containing alcohol do you have on a typical day when drinking?

• How often do you have six or more drinks on one occasion?

• During the past year, how often have you found that you were not able to stop drinking once you had started?

• During the past year, how often have you failed to do what was normally expected of you because of drinking?

SCREENING INSTRUMENTS FOR ALCOHOL MISUSE

• During the past year, how often have you needed a drinkin the morning to get yourself going after a heavy drinkingsession?

• How often during the last year have you had a feeling ofguilt or remorse after drinking?

• How often during the last year have you been unable toremember what happened the night before because you hadbeen drinking?

• Have you or someone else been injured as a result of yourdrinking?

• Has a relative or friend, doctor or other health worker beenconcerned about your drinking or suggested you cut down?

RELUCTANCE TO DISCLOSE ALCOHOL USE IN IDC CLINICS

A patient may be reluctant to disclose alcohol use in the IDC clinic:

May not see their alcohol use as a ‘problem’ or feel it is not worth mentioning

Alcohol use is normative and socially accepted in several parts of the country

Stigma, embarrassment , and fear of being judged for alcohol use

OVERCOMING RELUCTANCE TODISCLOSE ALCOHOL USE

The doctor/nurse/counsellor should: Remain non-judgmental; empathetic; genuine

Acknowledge that alcohol use can be difficult to talk about

Assure confidentiality

Obtain patient consent before taking history

CONSEQUENCES OF ALCOHOL USE

Has the patient experienced any problems as a result of using alcohol?:Medical problems

Family problems

Social relationship problems

Employment or financial problems

How long has the patient experienced these problems?

ALCOHOL DEPENDENCE

Three of the following six, in the last year:• strong desire or compulsion

• loss of control over intake

• tolerance (increasing quantity of alcohol to achieve the same effect)

• withdrawal state

• neglect of other interests, priority given to alcohol use

• persistent use despite evidence of harmful effects

ALCOHOL DEPENDENCE ASSESSMENTPHYSICAL EXAMINATION

Signs of intoxication

Signs of withdrawal

Signs of drug use-related liver disease and other medical conditions

TREATMENT FOR ALCOHOL DEPENDENCE Abstinence from alcohol is the mainstay of therapy in

alcohol-induced diseases

As few as 30% of patients with alcohol dependence eventually achieve sustainable abstinence

PHARMACOLOGICAL DRUGS USED IN THE TREATMENT OF ALCOHOL DEPENDENCE

Disulfiram

Acamprosate

Naltrexone

Topiramate

Baclofen

DOSE OF DRUGS USED IN ALCOHOL DEPENDENCE

Drug Dose

NaltrexoneOralIntramuscular injection

50–100 mg per day 380 mg per month

Acamprosate 666 mg three times per day

Naltrexone+acamprosate Same doses as above

Disulfiram 250 mg per day

Topiramate 300 mg per day

NON-MEDICAL TREATMENT FOR ALCOHOL DEPENDENCE Motivational Enhancement Therapy

Cognitive behaviour therapy

Family therapy

Group therapy

Self help groups – Alcoholic Anonymous

ALCOHOL WITHDRAWAL SYNDROME

DIAGNOSTIC CRITERIA FOR ALCOHOL WITHDRAWAL A. Cessation of (or reduction in) alcohol use that has been heavy and prolonged.

B. Two or more of the following are present:

autonomic hyperactivity (e.g. sweating or pulse rate greater than 100 beats per minute)

increased hand tremor insomnia nausea or vomiting transient visual, tactile or auditory hallucinations or illusions psychomotor agitation anxiety grand mal seizures.

American Psychiatric association, 2000

TIMELINE OF ALCOHOL WITHDRAWAL

CLINICAL MANIFESTATIONS OF ALCOHOL WITHDRAWALPhase Symptoms Onset after

last drinkDuration

Early withdrawal

TremulousnessAnxietyPalpitationsNauseaAnorexia

6–8 h 1–2 d

Withdrawal seizures

Generalized tonic-clonic seizures

6–48 h 2–3 d

CLINICAL MANIFESTATIONS OF ALCOHOL WITHDRAWALPhase Symptoms Onset after

last drinkDuration

Alcoholic hallucinosis

HallucinationsVisualTactileAuditory

12–48 h 1–2 d

Delirium tremens

TachycardiaHypertensionLow-grade feverDiaphoresisDeliriumAgitation

48–96 h 1–5 d

WHY IS IT SO IMPORTANT?

Common medical problem (8% of hospitalised inpatients at risk for alcohol withdrawal)

Mortality of alcohol withdrawal can be high (up to 15%)

May develop in patients admitted to hospital for an unrelated illness (e.g. for an operation)

Patients may present in a confused state to the Emergency Department, due to the onset of the withdrawal syndrome

HOW TO RECOGNIZE THE SYNDROME?

Tremor of extended hands, tongue or eyelids

Sweating

Nausea and/or vomiting

Sinus tachycardia

Psychomotor agitation

Insomnia

Anxiety

HOW TO RECOGNIZE THE SYNDROME?

Headache

Fever

Decreased attention

Disorientation

Clouding of consciousness

Hallucinations (which may be visual, tactile or auditory)

Withdrawal seizures

Delirium

HOW TO MANAGE THE SYNDROME?

The aims of detoxification are to:

provide safe withdrawal from alcohol and enable the patient to become alcohol free

provide withdrawal that is humane, thus protecting the patient’s dignity

prepare the patient for ongoing treatment for their dependence on alcohol

FIXED SCHEDULE OR SYMPTOM TRIGGERED REGIMENS?

Patients should be treated with regimens which are patient-specific and flexible to respond to changes in severity of withdrawal (symptom-triggered)

Fixed treatment schedules, where the patient is given a standard regimen irrespective of their symptoms, are inappropriate

WHEN TO TREAT?

Treatment should be initiated using a symptom-triggered regimen

Mile to moderate symptoms can be treated on an outpatient basis

Severe symptoms (Seizures, delirium) warrant inpatient admission and treatment

WHICH DRUG TO USE?

Benzodiazepines

Longer-acting benzodiazepines (e.g. diazepam) may be more effective in preventing seizures

May produce a smoother withdrawal course with less break-through or rebound symptoms than shorter-acting agents

Benzodiazepines with a rapid onset of action may have a higher abuse potential than those with slower onset of action

WHICH DRUG TO USE?

Anti-psychotics

In those patients who are still manifesting the signs of severe withdrawal despite appropriate doses of diazepam, haloperidol 5 mg IV or IM should be administered, repeated once, as appropriate

WHICH DRUG TO USE?

β-adrenoceptor blocking drugs reduce the autonomic features of withdrawal no anticonvulsant activity these drugs are known to cause delirium

Clonidine ameliorates mild to moderate withdrawal No efficacy in preventing seizures or delirium

WHICH DRUG TO USE? What is an ideal drug for alcohol withdrawal?

Few significant side effects

Wide margin of safety

A metabolism not dependent on liver function

Absence of abuse potential

ROLE OF THIAMINE

Thiamine

All patients should receive thiamine 100 mg bd orally, unless Wernicke’s encephalopathy or Korsakoff’s psychosis is suspected, when parenteral administration of B vitamins is appropriate

KEY MESSAGES Alcohol use related problems are enormous in India

Alcohol dependence is a chronic brain disorder with many adverse consequences

A comprehensive, holistic approach is needed

Detoxification, anti-caving medication, psychological therapies, self help groups constitute the holistic care

Symptom-triggered regimens have been shown to result in the administration of less total medication and to require a shorter duration of treatment

In most patients with mild to moderate withdrawal symptoms, outpatient detoxification is safe and effective, and costs less than inpatient treatment

Long acting benzodiazepines have been shown to be safe and effective, particularly for preventing or treating seizures and delirium, and are the preferred for treating alcohol withdrawal syndrome