A LCOHOL USE DISORDER

A LCOHOL USE IN I NDIA 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)

S CREENING INSTRUMENTS FOR ALCOHOL MISUSE CAGE C – 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?

S CREENING 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?

S CREENING INSTRUMENTS FOR ALCOHOL MISUSE During the past year, how often have you needed a drink in the morning to get yourself going after a heavy drinking session? How often during the last year have you had a feeling of guilt or remorse after drinking? How often during the last year have you been unable to remember what happened the night before because you had been drinking? Have you or someone else been injured as a result of your drinking? Has a relative or friend, doctor or other health worker been concerned about your drinking or suggested you cut down?

R ELUCTANCE 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

O VERCOMING RELUCTANCE TO DISCLOSE 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

C ONSEQUENCES 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?

A LCOHOL 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

A LCOHOL DEPENDENCE ASSESSMENT PHYSICAL EXAMINATION Signs of intoxication Signs of withdrawal Signs of drug use-related liver disease and other medical conditions

T REATMENT 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

P HARMACOLOGICAL DRUGS USED IN THE TREATMENT OF ALCOHOL DEPENDENCE Disulfiram Acamprosate Naltrexone Topiramate Baclofen

D OSE OF D RUGS USED IN A LCOHOL D EPENDENCE DrugDose Naltrexone Oral Intramuscular injection 50–100 mg per day 380 mg per month Acamprosate666 mg three times per day Naltrexone+acamprosateSame doses as above Disulfiram250 mg per day Topiramate300 mg per day

N ON - MEDICAL TREATMENT FOR ALCOHOL DEPENDENCE Motivational Enhancement Therapy Cognitive behaviour therapy Family therapy Group therapy Self help groups – Alcoholic Anonymous

A LCOHOL W ITHDRAWAL S YNDROME

D IAGNOSTIC 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

T IMELINE OF ALCOHOL WITHDRAWAL

C LINICAL MANIFESTATIONS OF ALCOHOL WITHDRAWAL PhaseSymptomsOnset after last drink Duration Early withdrawal Tremulousnes s Anxiety Palpitations Nausea Anorexia 6–8 h1–2 d Withdrawal seizures Generalized tonic-clonic seizures 6–48 h2–3 d

C LINICAL MANIFESTATIONS OF ALCOHOL WITHDRAWAL PhaseSymptomsOnset after last drink Duration Alcoholic hallucinosis Hallucinations Visual Tactile Auditory 12–48 h1–2 d Delirium tremensTachycardia Hypertension Low-grade fever Diaphoresis Delirium Agitation 48–96 h1–5 d

W HY 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

H OW TO RECOGNIZE THE SYNDROME ? Tremor of extended hands, tongue or eyelids Sweating Nausea and/or vomiting Sinus tachycardia Psychomotor agitation Insomnia Anxiety

H OW TO RECOGNIZE THE SYNDROME ? Headache Fever Decreased attention Disorientation Clouding of consciousness Hallucinations (which may be visual, tactile or auditory) Withdrawal seizures Delirium

H OW 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

F IXED 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

W HEN 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

W HICH 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

W HICH 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

W HICH 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

W HICH 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

R OLE 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

K EY 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