How To Work With A Comorbidity

Audit of Alcohol Detoxification

Prescribing Observatory for Mental Health

(POMH-UK) Regional Event

Wakefield 4th December 2013

Wakefield 4th December 2013

Duncan Raistrick

Leeds Addiction Unit

definition and

guidance

Detoxification

What...

Detoxification is the process of rapidly achieving a drug

free state – normally 7-14 days. It is different to slow

reduction programmes and requires

good preparation

work between therapist and service user.

When...

Action stage: self efficacy, self esteem and positive

outcome expectancy or expedience

Where...

Assess risk and determine level of supervision required

Lifetime prevalence and odds ratio of Mental

Illness and Substance Misuse

alcohol % OR cannabis % OR cocaine % OR opiates % OR Schizophrenia 3.8 3.3 6.0 4.8 16.7 13.2 11.4 8.8 Schizophrenia Affective Anxiety Antisocial 3.8 3.3 13.4 1.9 19.4 1.5 14.3 21.0 6.0 4.8 23.7 3.8 27.5 2.3 14.7 8.3 16.7 13.2 34.7 5.9 33.3 2.9 42.7 29.2 11.4 8.8 30.8 5.0 31.6 2.8 36.7 24.3

Note the range of prevalence both by mental illness category and substance use category – look down and across the pale yellow numbers. The OR for the general population is 1.

Some Problems in Working with Comorbidity

• Organisational

range of competencies needed

multi-agency working – communication barriers, differing ethos clarity of roles at agency and practitioner levels

• Service users

utility of substance usey

substance use and mental illness feed each other inconvenience of going to several agencies

need to build therapeutic alliance at agency and therapist levels

• Practitioners

training to develop a range of skills

need for support and supervision to deal with complex cases therapeutic pessimism

Strength of BAP recommendations rated A to D based on evidence British Association of Psychopharmacology 2012:

NICE Guidelines on Alcohol Use Disorders:

2011 Diagnosis, assessment and management of harmful drinking and alcohol dependence

2010 Diagnosis and clinical management of alcoholDiagnosis and clinical management of alcohol--related physical related physical complications

complications

2010 Preventing harmful drinking 2010 Preventing harmful drinking

summarising guidelines....

Treatment of uncomplicated withdrawal....

Benzodiazepines

are efficacious in reducing signs

and symptoms of withdrawal (A); fixed-dose

regimens are recommended for routine use with

symptom-triggered dosing reserved for use only with

adequate monitoring (D)

Carbamazepine

has also been shown to be equally

efficacious to benzodiazepines (A)

Clomethiazole

is reserved for inpatient settings only

after due consideration of its safety (A)

Treatment of complicated withdrawal....

Seizures

Benzodiazepines, particularly diazepam, prevent de novo seizures (A)

Anticonvulsants are equally as efficacious as benzodiazepines in seizure prevention, but there is no advantage when combined (A)

In preventing a second seizure in the same withdrawal episode, lorazepam but not phenytoin has been shown to be effective (A) Delirium

Benzodiazepines, particularly those with longer half-life prevent delirium (A) and should be used for treatment (B)

Alcohol Withdrawal Symptoms

Most Common Most Specific

1 Depression Whole body shakes

2 Anxiety Facial tremulousness

3 Irritability Hand and finger shakes

Tremulousness (6-12hrs) Seizures (24-36 hrs) Delirium (48-72 hrs)

4 Tiredness Cannot face the day

5 Craving Panicky

6 Restlessness Guilt

7 Insomnia Nausea

8 Confusion Visual hallucinations

9 Sweating Weakness

10 Weakness Depression

Source: Hershon (1977) J Stud Alc

basic

pharmacotherapy

General Methods of Detoxification

Front loading

Repeat dosage eg for alcohol diazepam 20mg every 90min until severity of withdrawal score below preset level. No further medication given. Efficient in staff time and reduces total dose.

Fixed dose reduction

A predetermined regimen for a given severity of withdrawal. Does not require experienced staff. Not sensitive to need and unlikely to pick up complications.

Variable dose reduction

Dose of medication is determined by the severity of withdrawal. Requires experienced and trained staff. Best method where the course of detoxification is uncertain.

Typical Withdrawal Medication

Chlordiazepoxide(or diazepam in half the dose)

severe withdrawal 30mg qds reduce over 5days moderate withdrawal 20mg qds reduce over 5days Oxazepam(liver disease)

severe withdrawal 30mg qds reduce over 5days moderate withdrawal 20mg qds reduce over 5days Lorazepam(seizures or delirium)

30mcg/kg = 1.5-2.5mg IM or slow IV repeat 6hrly Chlormethiazole(in patient only)

very severe withdrawal with history of seizures/delirium 2-4 caps day1 6-8 day2 reduce over 9days

Oxcarbamazepine(2nd_{line drug)}

Front loading method of detox

Assessed every 90mins – 20mg of diazepam if CIWA score >=11 – stop after x2 CIWA scores <=10. Total 222mg chlordiazepoxide vs 700mg standard Rx

Source: Day et al. (2004) Psychiatric Bulletin

Prevention of Wernicke’s encephalopathy....

Low risk: healthy uncomplicated alcohol-dependent/heavy drinkers - oral thiamine 300 mg/day during detoxification (D)

High risk: malnourished, unwell - prophylactic parenteral treatment 250 mg thiamine (one pair of ampoules Pabrinex®) i.m. or i.v. once daily for 3–5 days or until no further

i t (D)

improvement (D)

Suspected WE: parenteral thiamine (i.m. or i.v.) 500 mg daily for 3–5 days (two pairs of ampoules Pabrinex®), followed by one pair of ampoules daily for a further 3–5 days depending on response (D)

Wernicke-Korsakoff Syndrome

Ophthalmoplegia 29%

25-30mg thiamine stored in liver, heart, brain and kidneys.

Daily turnover approx 1mg - absorption from 10mg thiamine

or more is 4-5mg in healthy individuals, 0.75-1.5mg in

heavy drinkers

Diagnosis (only 10% have full triad):

Ophthalmoplegia 29%.

Ataxia (not due to intoxication) 23%.

Impaired memory function.

Confusion or impaired consciousness (not due to

intoxication) 82%.

Unexplained hypotension or hypothermia.

>85% cases are subclinical or undiagnosed.

Prevention of Neurotoxicity

there is insufficient clinical trial evidence to include in guidance

• Acamprosate

may be effective at blocking the

neurotoxicity caused by glutamate during alcohol

withdrawal – other anti-glutamatergic agents also

effective

• Mifepristone

may be effective at blocking the

neurotoxicity caused by corticosterone during alcohol

withdrawal – there are other possible targets to block

the stress reaction

Dead Alcohol Withdrawal + Acamprosate Control Alcohol Withdrawal

In alcohol withdrawal the brain is both over-stimulated (high glutamate) and under-inhibited (low GABA). Too much glutamate may cause cell death.

Acamprosate may reduce this damage during alcohol withdrawal.

Alive

courtesy of Prendergast & Littleton

relapse prevention

Relapse prevention - guidance is

inconsistent and needs clinical view....

Acamprosateimproves abstinence rates (A) and reduces alcohol consumption (A)

Naltrexonereduce risk of lapse becoming a relapse - less evidence of maintaining abstinence (A)

Disulfiramto maintain abstinence if no contraindications (B) Baclofento maintain abstinence if high levels of anxiety (C) SSRIsshould be avoided

Alcohol Neurochemistry

The pharmacology of alcohol is not well understood. There are four known effects of alcohol albeit these may be partial effects.

Acamprosatehas one agonist and one antagonist effect just like alcohol. It is not itself intoxicating – any effect is by changing the natural tonic status of GABA and glutamate systems.

The rationale for naltrexoneis that it blocks the mu effect of alcohol and so is only needed when drinking occurs.

20 25 30 35 40 45 50

Acamprosate vs Disulfiram vs Naltrexone

a randomised controlled trial

0 5 10 15

Days to Heavy Drinking Days to Drinking Days Abstinence /wk

Acamprosate Disulfiram Naltrexone

Source: Laaksonen et al. (2008) Alcohol and Alcoholism

243 subjects randomised 1:1:1 supervised medication + manualised CBT. Alcohol consumption reduced from approx 580gm weekly to 195gm (ACA) 109gm (DIS) 229gm (NTX) at 2yr follow-up

Disulfiram blocks aldehyde dehydrogenase causing a

build up of acetaldehyde – blocks

dopamine-b-hydroxylase causing a build up of dopamine

Caution in psychotic mental illness

Caution with cardiovascular disease

Suicidal Behaviour Post Detoxification

n=470 Suicidal Ideation Suicide Attempt

Lifetime 28.5% 21.9% 24 th P t D t 19 9% 6 9% 24mths Post Detox prior ideation no prior ideation 19.9% 46.5% 8.4% 6.9% 24.1% 2.3%

Source: Wines et al., (2004) Drug and Alcohol Dependence

points to consider

preparation timing of follow up staff attitudes

Detoxification Preparation

Preparation is based on a dialogue between the keyworker, service user and other carers.

o Determining readiness for detoxification and highlighting positive outcomes.

o Coping strategies other than pharmacotherapy for dealing with withdrawal symptoms.y p

o Identifying a support person and plan for the detoxification period. o---o Identifying a po---ost deto---oxificatio---on plan.

o Revisiting learning points from previous detoxifications. o Assessing risks.

o Making a follow on keyworker appointment.

Audit

outcome

at 1month

Doing anything depends on staff attitudes...

Max score = 25 On each subscale Role adequacy Role legitimacy Positive

expectancy Self efficacy Overall therapeutic attitude Health Care Assistants 2007 11.1 11.4 11.4 9.9 43.7% 2013 9.5 9.2 9.2 8.9 36.8% Nurses 2007 10.3 8.5 11.5 9.4 39.7% 2013 8.1 8.0 8.3 7.7 32.1% Doctors 2007 9.4 6.0 13.5 10.5 39.4% 2013 7.2 7.5 7.0 7.0 28.6%

Doctors under 30yrs scored OTA = 41.0 older doctors OTA = 23.8