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1 Management of substance use related disorders in primary care 2 nd October 2010 PEMSA Reunion meeting Dr. E K Rodrigo MBBS,MD, FRCPsych, FSLCP & FRANZCP & FRANZCP Senior Staff Specialist in Psychiatry Senior Staff Specialist in Psychiatry ACT MENTAL HEALTH ACT MENTAL HEALTH Slide 2 2 Clinical suspicion Assume all patients have an alcohol and /or tobacco use problem unless proved otherwise Ask all health care patients about their alcohol and tobacco use Slide 3 3 HARM ASSOCIATED WITH ALCOHOL USE Most drinkers (73%) generally consume alcohol in ways considered a low health risk (AIHW, 2002). Harmful/hazardous alcohol use and dependence is estimated to cost the Australian community $7.6 billion in direct and indirect costs (Collins & Lapsley,2002). Single episodes of alcohol intoxication contribute to 67% of potential years of life lost (PYLL) due to premature alcohol-related mortality (CDHAC, 2001). Slide 4 4 ICD-10 criteria for the alcohol dependence syndrome 3 or more of the following manifestations should have occur together for at least 1 month or if persisting for periods of less than one month should have occurred together repeatedly within a 12 month period A strong compulsion to consume alcohol Impaired capacity to control drinking A physiological withdrawal state Evidence of tolerance Preoccupation with alcohol,; Persistent alcohol use despite clear evidence of harmful consequences, WHO-1993 Slide 5 5 THE CAGE QUESTIONNAIRE Ever felt to Cut down your drinking ? People Annoyed you by criticizing your drinking ? Ever felt Guilty about your drinking ? Ever had a drink first thing in the morning as an Eye opener ? Two or more positive replies identify problem drinkers; one is an indication for further enquiry about the persons drinking. Slide 6 6 Slide 7 7 DIAGNOSTIC FEATURES SIGNS OF HARMFUL ALCOHOL USE HEAVY ALCOHOL USE HEAVY ALCOHOL USE GAMA GT MCV Carbohydrate deficient transferrin CDT Slide 8 8 MANAGEMENT GUIDELINES ESSENTIAL INFORMATION FOR PATIENT AND FAMILY 1-alcohol dependence is a serious illness. stopping or reducing alcohol use will bring mental and physical benefits 2-drinking during pregnancy can harm the baby 3-in some cases of harmful alcohol use without dependence, controlled or reduced drinking is a reasonable goal 4-for patients with alcohol dependence, abstinence from alcohol is the goal. Cont.. Slide 9 9 SPECIFIC COUNSELLING TO PATIENT AND FAMILY 1)For those willing to stop now Set a definite day to quit Discuss strategies to avoid or cope with high-risk situations (e.g.. social situations, stressful events) Make specific plans to avoid drinking use (e.g.. ways to manage stressful events without alcohol, hoe to respond to friends who still drink) Identify family or friends who will support stopping alcohol use Slide 10 10Cont. SPECIFIC COUNSELLING TO PATIENT AND FAMILY 1-for those willing to stop now: Set a definite day to quit Discuss strategies to avoid or cope with high risk situations Makes specific plans to avoid drinking use Identify family or friends who will support stopping alcohol use 2-if reducing drinking is a reasonable goal (or if patient is unwilling to quit) Negotiate a clear goal for decreased use Discuss strategies to avoid or cope with high risk situations Slide 11 11 cont. 2)if reducing drinking is a reasonable goal (or if patient is unwilling to quit) Negotiate a clear goal for decreased use (No more than two drinks per day with two alcohol free days per week ) Discuss strategies to avoid or cope with high risk situations (eg: social situations,stressful events) Introduce self monitoring procedures and safer drinking behaviors. (time, slowing down drinking) 3) For patients not willing to stop or reduce use now : Do not reject or blame. Clearly point out medical and social problems caused by alcohol. Make a future appointment to discuss drinking. 4) Self- help organizations. (e.g. ;Alcoholic Anonyms) are often helpful. Slide 12 12 Elements of brief intervention Present screening results Identify risks and discuss consequences Slide 13 13 ELEMENTS OF TREATMENT MotivationEngagementDetoxificationAbstinenceRehabilitation Slide 14 14 IN- PATIENT DETOXIFICATION Current severe withdrawal History of severe withdrawal Imminent withdrawal Illnesses. pneumonia, pancreatitis Poly drug use Suicidal ideation / severe depression Slide 15 15 Community based detoxification Out patient Home based More acceptable More accessible As safe and effective Cheaper Than in-patient treatment Slide 16 16 PHARMOCOLOGICAL THERAPIES DETOXIFICATION BENZODIAZIPINES AVERSION AGENTS DISULFIRAM CRAVING REDUCTION AGENTS NALTREXONE ACAMPROSATE SSRI FLUOXETINE DOPAMINE AGONISTS BROMOCRIPTINE TIAPRIDE Slide 17 17 Advise patients not to drink When operating a machinery or vehicle When pregnant or considering pregnancy If a contraindicated medical condition is present After using certain medications, such as sedatives, analgesics, and selected antihypertensive Slide 18 18 ADVICE TO INDIVIDUALS 1) As a general rule, not more than 2 drinks in any day 2) Lower levels are appropriate for specific groups 3)Current abstainers are advised not to begin drinking in order to reduce health risks 5) Those who drink more than 2 drinks a day are advised to cut down 6) One drink-free day per week is recommended to minimize risk of dependence 7) It is advisable to avoid intoxication 8) Pregnant women are advised to abstain 9) In certain circumstances it is best not to drink at all 10)People considering increasing their drinking should consult the doctor first VISUAL AID A 4 Slide 19 19 Whats a low risk limit No more than two standard drinks a day Do not drink at least two days of the week But remember: there are times when even one or two drinks can be too much-for example: When driving or operating machinery When pregnant or breast feeding When taking certain medication If you have certain medical conditions If you cannot control your drinking Ask your health care provider for more information Slide 20 20 WORKING WITH ILLITERATE PATIENTS Patients who are illiterate or have poor reading ability will require special help in brief counseling situations. it's recommended that the health care worker review the self-help booklet with the patient, assist in filling out the plan, and (if the patient is willing) suggest that the patient give the materials to a family member or a friend who might assist in reminding the patient of its contents. Slide 21 21 Cont .. Medication 1) Withdrawal from alcohol may require use of anti- anxiety drugs (Benzodiazepines, e.g.: lorazepam.5 to 2 mg up to) but out patient use should be closely monitored 2) Disulfiram may help to maintain abstinence from alcohol in some cases, but routine use is not necessary Slide 22 22 SPECIALIST CONSULTATION Severe alcohol withdrawal ( with hallucinations and autonomic instability) may require hospitalization, and use of higher dose anti- anxiety drugs. Slide 23 23 Slide 24 24 WEIGHING UP THE PROS AND CONS Why I want to stop smoking ------------------- Why I enjoy About smoking -------------------- Where does that leave me now ? Slide 25 25 PROBLEM PREDICTOR On the first day: The biggest problem will be -------------------------------------------------------------------------------------------------------------- The solution is -------------------------------------------------------------------------------------------------------------- During the first week: The biggest problem will be.. -------------------------------------------------------------------------------------------------------------- The solution is.. -------------------------------------------------------------------------------------------------------------- Other problems during the first week.. --------------------------------------------------------------------------------------------------------------Solutions..-------------------------------------------------------------------------------------------------------------- Slide 26 26 TOP STOP TIPS Something in your mouth Do something with your hands (find something to fiddle with-a pencil, coin, worry beads..) Dont forget the habit-breaking principle Save your cigarette money Set up a special savings account Something to remind you (clean out an old jam jar and fill it with cigarette butts) Slide 27 27 MANAGEMENT GUIDELINES Essential information for patient and family 1) any amount of tobacco use may have harmful health effects 2) using tobacco during pregnancy may harm the baby 3) discontinuing tobacco use should improve health now and in the future Slide 28 28Cont Specific counseling to patient and family 1) for patients now willing to quit Set a definite date for quitting Discuss high risk situations for resuming tobacco use (e.g. socializing with friends who use tobacco) Make specific plans to avoid resuming tobacco use (e.g. discuss how to respond to friends who offer cigarettes) Identify friends or family members who support stopping tobacco use 2)for patients not now willing to quit Do not reject or blame Clearly point out current and future health effects of continued tobacco use. Make a future appointment to discuss tobacco use 3)group counseling programs may be helpful if available Provide medical advice Solicit patient commitment Identify goal-reduced drinking or abstinence Give advice and encouragement Slide 29 29 Cont MEDICATION Nicotine preparations may help reduce nicotine withdrawal symptoms. these should not be used without counseling described in #1 above BupropionVarenicline Slide 30 Enhancing Motivation to Quit Tobacco: the 5 Rs* RelevanceRisksRewardsRoadblocksRepetition Slide 31 31 Special treatment for drinking problems Psychological treatment Motivation interviewing Motivation interviewing Broad spectrum cognitive behavior approaches Broad spectrum cognitive behavior approaches Relapse prevention and community reinforcement. Relapse prevention and community reinforcement. Slide 32 32 Cognitive behavioral techniques Anxiety management Anger management Skills training Social Problem solving Drink refusal Behavioral control training Cue exposure Marital and family therapy Slide 33 33 HIGH RISK SITUATION EMERGENCY PLAN I will leave/ change situation I will put off decision to drink by 15 minutes I will change my thoughts I will think of some thing else I will remind myself of my success I will call for help Slide 34 34 MANAGING COMMON THOUGHTS LEADING TO RELAPSE EscapeRelaxationSocialization Improved self image Romance To hell with it No control Slide 35 35 Motivation enhancement Express empathy Develop discrepancy Avoid argumentation Roll with resistance Support self efficacy Slide 36 36 Coping with craving / urges Recognize triggers Exposure to alcohol Seeing others drink Contact with People Places Times of day Situations Emotions-frustration Physical states Slide 37 37 The evidence for brief intervention Bien,et al 9.- considered 32 controlled studies involving 6000 patients, finding that brief interventions were often as effective as more extensive treatment Kahan, et al 10.-the public health impact of brief intervention is potentially enormous Wilk, et al 11.-drinkers receiving a brief intervention were twice as likely to reduce their drinking over 6-12 months than those who received no intervention Moyer et al 12.-brief intervention should not substitute for specialist treatment. they might well serve as an initial treatment for severely dependent patients seeking extended treatment. Slide 38 Department of Health Webpages http:// www.health.gov.au/internet/main/publishing.nsf /Content/phd-aodgp http:// www.health.gov.au/internet/main/publishing.nsf /Content/phd-aodgp http://www.health.gov.au/internet/main/publishing. nsf/Content/portal-Alcohol http://www.health.gov.au/internet/main/publishing. nsf/Content/portal-Alcohol http://www.health.gov.au/internet/main/publishing. nsf/Content/tobacco-res http://www.health.gov.au/internet/main/publishing. nsf/Content/tobacco-res http://www.health.gov.au/internet/main/publishing. nsf/Content/portal-Tobacco http://www.health.gov.au/internet/main/publishing. nsf/Content/portal-Tobacco 38 Slide 39 39