Medical and Specialist Interventions in Alcohol Dependence Peter Rice, Consultant Psychiatrist, NHS Tayside

Peter Rice Oct 08 ICD-10 Dependence Syndrome -Diagnosis requires at least 3 phenomena in past year Difficulty in controlling use of drug in terms of onset, termination and level of consumption. Increasing tolerance for drug (declining tolerance as a late phenomenon) Physiological withdrawal state on cessation or use of drug to avoid withdrawals. Strong desire or sense of compulsion to alcohol use. Progressive neglect of other interests. Persisting with use despite clear evidence of harmful consequences that the user is aware of.

ALCOHOL WITHDRAWAL SYNDROME MildSevere Onset hrs after last drink Onset hrs Fine tremor with arms extendedGross tremor at rest SweatingMarked sweating AnxietyAcute panic Irritability Aggressive Poor sleepInsomnia Perceptual changes Light sensitivityVisual Hallucinations ItchingTactile hallucinations Hyperascusis Auditory hallucination Slowed thinkingDisorientation. Tachycardia / hypertension Tachycardia/hypertension

MANAGEMENT OF ALCOHOL WITHDRAWAL - Assess risk from history - Explanation will reduce symptom severity. - Gradual alcohol reduction, 25% per day will work -Long acting benzodiazepines. Chlordiazepoxide is drug of choice. - Adequate initial dose eg CDP 90 mg/ day, tail off over max of 7 days. - Insomnia may persist, best to warn about this. Avoid long term hypnotics. - Watch out for nutritional defiency. (Wernicke-Korsakov synd)

TREATMENT OUTCOMES IN ALCOHOL MISUSE -Strong evidence base for brief interventions in some specific settings for problem use -Strong evidence base for some psychological and Pharmacological interventions. -Interventions highly cost-effective, even allowing for high dropout rates. - UK treatment services of limited capacity. Dept of Health estimates capacity for approx 6% of potential need.

Which treatment or combination of treatments (pharmacological and psychosocial) will best prevent relapse in alcohol dependent patient who have been detoxified? What is the most effective and efficient approach to delivering treatment taking into account the different risk groups, locations, durations of treatment, etc?

From more than 40 nominally different therapies four psychosocial therapies were supported by good evidence of effectiveness in people with alcohol dependence. These should be available in specialist centres: Motivational Enhancement Therapy Coping/Social Skills Training Marital/Family Therapy Behavioural Self Control Training

These psychosocial (talking therapies) may be supplemented by: acamprosate (Campral  ) supervised oral disulfiram (Antabuse  ) Naltrexone not recommended for routine use

OUTCOMES OF INTERVENTION GP and HOSPITAL ADVICE - Numbers of heavy drinkers will half HOME DETOX - 37% of dependent drinkers abstinent at 1 year PSYCHOLOGICAL TREATMENT -35% abstinent at 1 year - 20% no benefit DRUG TREATMENT - Acamprosate doubles abstinent rates vs control group NATIONAL STRATEGIES - France, Italy reduced consumption by 35-50% in past 25 years. Restricting availabilty, advertising and sponsorship, health education. UK Consumption risen by 25%

RELAPSE PREVENTION IN ALCOHOL DEPENDENCE DISULFIRAM (Antabuse) Interferes with alcohol metabolism, leading to acetaldehyde accumulation after alcohol. Reaction :Flushing, dyspnoea, dizziness, hypotension. Wide individual variation. Patient needs to know that reaction MAY be very serious. Risk of reaction 7 days after last dose. Drowsiness commonest SE. Rarely liver, confusion, skin rash, psychosis. Use 200 mg daily. Should be psychological support available. Effectiveness increased by supervised administration.

ACAMPROSATE Reduces activity of excitatory neurotransmitter Glutamate. Probably via NMDA blockade. Clinical action is to reduce intensity of craving in response to alcohol cue. Typical RCT outcome is to double rates of abstinence. Use in France for 25 yrs. UK licence for 15 yrs. Well tolerated and safe. Commonest SE is GI upset. No evidence of dependence. Keep using during drinking lapse. Maintain as long as patient feels it’s making a difference. Stop if no benefit in 6 months. RELAPSE PREVENTION IN ALCOHOL DEPENDENCE

THE UNMET NEED FOR ALCOHOL SERVICES IN THE UK PREVALENCE SERVICE UTILISATION RATIO INTERNATIONAL NORMS High Access 1:5 Low Access 1:10 UK PERFORMANCE England 1:18 Scotland 1:12

Cost Effectiveness Recent studies suggest that alcohol treatment has both short and long-term economic benefits. The Review of the effectiveness of treatment for alcohol problems suggests that provision of alcohol treatment to 10 per cent of the dependent drinking population within the UK would reduce public sector resource costs by between £109 million and £156 million each year. Analysis from the United Kingdom Alcohol Treatment Trial suggests that for every £1 spent on alcohol treatment, the public sector saves £5.