ALCOHOL, DRUGS AND HOSPITALS James Bell. At this completion of this session, you will be able To...
-
Upload
beryl-webster -
Category
Documents
-
view
213 -
download
0
Transcript of ALCOHOL, DRUGS AND HOSPITALS James Bell. At this completion of this session, you will be able To...
At this completion of this session, you will be able • To take a drug and alcohol history• To provide brief intervention• To use screening and monitoring questionnaires• Outline management of alcohol withdrawal• Respond constructively to IDU admitted to
hospital
Learning Objectives
Who develops drug problems?
0
5
10
15
20
25
Pre
va
len
ce
18-24 25-34 35-44 45-54 55-64 65+
Age
Males (9.0)
Females (3.2)
Neurobiology of drug use
• Drugs of abuse have in common that they act on the “reward pathway”
• The reinforcing effect of drugs is reduction in anxiety and creation of a sense of well-being
• Repeated exposure leads to lasting brain changes, including protracted withdrawal
A maladaptive pattern of substance use leading to impairment or distress
Tolerance and WithdrawalSalienceCravingReinstatement after abstinencePersisting use despite harm
Drug Dependence
Communities vulnerable to drug dependence
Those without taboos or rewards
Especially: - indigenous communities - marginalised communities- deregulated communities
Distinct area of medicine:• Serious morbidity and mortality• Involves values and choices
Simply telling people to stop is of limited value
Responding to drug problems
Components of behavioural medicine
• Exchange of information
• Structure
• Support
• Relief of symptoms
Admissions with alcohol problems KCH (2009)
CARE_GROUP Elective Emergency Non-Elective TotalCardiac 44 25 16 85
Child Health 1 14 1 16CSDS 4 4Dental 7 26 3 36Liver 465 191 109 765
Medical 8 1716 8 1732Neurosciences 26 38 49 113
Renal 15 25 7 47
Specialist Medicine 3 23 26Surgical 67 231 13 311
Women's Health 3 3 6Grand Total 643 2292 206 3,141
Health Effects
GIT – liver, pancreas, stomachNeurological – WKS, cerebellar
ataxia, peripheral neuropathy, siezures
Trauma while intoxicatedMental health
Thiamine
Offer prophylactic oral thiamine to harmful or dependent drinkers: − a) malnourished or at risk of malnourishment − b) decompensated liver disease or − c) in acute withdrawal − d) before and during a planned medically assisted detoxification
Offer prophylactic parenteral thiamine to a and b above who attend an emergency department or are admitted to hospital
High dose parenteral thiamine for Wernickes encephalopathy
Alcohol consumption in men and women and risk of social and health problems
Alcohol Intake (units/week)
Risk of Problems
Men 0-21
Women 0-14
Low
Men 22-50
Women 15-35
Increasing
(Hazardous)
Men >50
Women >35
High
(Harmful)
Alcohol content of what other people drink
BEVERAGE APPROXIMATE ALCOHOL CONTENT (%)
UNITS OF ALCOHOL PER CONVENTIONAL MEASURE (1 unit=8g=10mL)
BEER AND CIDER
i) Ordinary beer 3 1.5 per can (2 per pint)
ii) Strong beer 4.6 – 6.0 3 per can (4 per pint)
iii) Extra-strong beer 7.5 – 9.0 4 per can (5 per pint)
iv) Cider/Strong cider 4/6 3 / 4 per pint
WINE (eg table wine) 10-14 8-10 per bottle (2-3 per glass)
FORTIFIED WINES (eg sherry, port)
13-16 13 per bottle(1 per small standard measure)
SPIRITS ( eg whisky, gin, brandy, vodka)
38-40 30 per bottle(1 per standard single measure)
1. All patients
Document alcohol (& drug use) history
Consider Alcohol Problems (Index of suspicion)
- alcohol-related disease
- alcohol dependence
Optimal Responses
When did you last drink alcohol?
How much did you drink on that day?
And the drinking day before that…
Check whether last 2 drinking days were typical
Calculate units/week
Alcohol History
Screening Questionnaires - FAST
1. How often have you had 6 or more units if female, or 8 or more if male, on a single occasion in the last year?
Only answer the following questions if the answer above is Never (0), Monthly (1) or Less than monthly (2). Stop here if the answer is Weekly (3) or Daily (4).
2. How often during the last year have you failed to do what was normally expected from you because of drinking?
3. How often during the last year have you been unable to remember what happened the night before because you had been drinking?
4. Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested that you cut down?
Index of Suspicion
• Presents intoxicated / smelling of EtOH
• Isolated raised GGT• Alcohol-related disease
Optimal Responses 2
2. Patients drinking above recommended limits
• Provide advise on safe levels• Personalise health risks• FU monitoring by GP• If being admitted• Monitor for withdrawal
Optimal Responses 3
3. In patients requesting help, referral to local services
Southwark
– Foundation 66
Lambeth
- Lorraine Hewitt House 02032281500
Or contact hospital substance misuse nurse
FeaturesAutonomic overactivity (tachycardia, hypertension, fever, sweating,
agitation, coarse tremor)
Perceptual disturbances (vivid dreams, illusions, hallucinations) – such as seeing snakes, feeling insects crawling on the skin (“formication”).
Disturbances of cognition, apprehension, paranoia, and delirium
GIT disturbances
Seizures may occur (usually 7-24 hours after last drink)
Rarely, proceeds to agitated, tremulous delirium (DTs)
Alcohol Withdrawal
Alcohol Withdrawal ScalePatient Name_______ DOB _______ Date
Time ___ ___ ___ ___ ___
Perspiration ___ ___ ___ ___ ___
Tremor ___ ___ ___ ___ ___
Anxiety ___ ___ ___ ___ ___
Agitation ___ ___ ___ ___ ___
Temperature ___ ___ ___ ___ ___
Hallucinations ___ ___ ___ ___ ___
Orientation ___ ___ ___ ___ ___
TOTAL ___ ___ ___ ___ ___
(Parenteral pabrinex) (supportive nursing care)
Prevent rather than manage withdrawal
Chlordiazepoxide protocol
Management of Alcohol Withdrawal
Chlordiazepoxide
Score 4-8: GIVE 20mg, REVIEW in 2 hours
If AWS score stable, continue 20mg QID day 1, then taper
Score is >8: GIVE 40mg and REVIEW in 2 hours
If AWS score stable or falling, continue chlordiazepoxide 40mg QID
If patient becomes sedated at any point, withhold chlordiazepoxide
Management of Alcohol Withdrawal
ResponsesPatient Action
All presentations to ED, and wards Alcohol, smoking, drug use documented
Patient drinking >21 units/week, Brief advice on safe drinking,
Alcohol related presentation monitor with AWS
_____________________________________________
In alcohol withdrawal* Initiate withdrawal protocol
Acute risk of withdrawal
Alcohol-related disease consult alcohol liaison nurse
Requesting help with drinking (Working hours)
_____________________________________________
*If patient presents to ED in withdrawal, is too unwell to be safely sent home, and has no other medical reason for admission to KCH, contact AAU re transfer of patient for continuing management.
1. Controlled Supply
2. Stabilization (minimize intoxication and withdrawal)
3. Diminish reinforcing effects of street heroin
4. Structure – attendance and monitoring
5. Support
Opioid Substitute Treatment of Addiction
Person on methadone (or buprenorphine) admitted
1. Continue medication
2. In addition, usual analgesia, may need titration
3. If head injury / hepatic encephalopathy, may need dose reduction
4. Note drug interactions (anticonvulsants, rifampicin, other CYP inducers)
Heroin User Admitted
1. Appropriate to initiate methadone in order to avoid withdrawal
2. Beware low tolerance, initiate 20mg, may repeat in 4 hours
3. Generally 40mg/day is sufficient to block withdrawal
4. Do not admit simply to manage heroin withdrawal
GBL
GABA b agonist, precursor of GHB• Produces confidence, charm, relaxation
(“charisma”), sexual disinhibition• In higher doses produces prompt sleep• Narrow therapeutic index – risk of OD• Usage mainly in gay males
GBL - Dependence
• Uncommon?
• Involves dosing every 1-2 hours
• Can develop rapidly (eg after a “long weekend” of partying)
• Often occurs when drug is used for sleep
• Associated with social withdrawal, emotional blunting, compromised social role
Onset rapid – 3-4 hoursCan occur after awaking from ODMay be severe (delirium, agitated psychosis,
severe anxiety and insomnia)Several cases required ICU management
UK experience – people admitted for elective detox have required ICU transfer (delirium, rhabdomyolysis)
GBL Withdrawal
GBL Withdrawal and Management
• Initiate high dose diazepam (20mg 2nd hourly) early. “Usual” dose 70-90 mg day 1
• Baclofen 10mg tds• Transfer to AAU (more appropriate
setting)