1. ALCOHOL, DRUGS AND HOSPITALS James Bell

2. 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

3. Why do people use drugs?

4. Drug use is normal behaviour Why do people use drugs?

5. Who develops drug problems?

7. 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

8. A maladaptive pattern of substance use leading to impairment or distress Tolerance and Withdrawal Salience Craving Reinstatement after abstinence Persisting use despite harm Drug Dependence

9. Communities vulnerable to drug dependence Those without taboos or rewards Especially: - indigenous communities -marginalised communities -deregulated communities

10. 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

11. Components of behavioural medicine Exchange of information Structure Support Relief of symptoms

12. Alcohol and hospitals

13. Alcoholics need not apply

14. Admissions with alcohol problems KCH (2009) CARE_GROUPElectiveEmergency Non- Elective Total Cardiac44251685 Child Health114116 CSDS44 Dental726336 Liver465191109765 Medical8171681732 Neurosciences263849113 Renal1525747 Specialist Medicine32326 Surgical6723113311 Women's Health336 Grand Total64322922063,141

15. Health Effects GIT – liver, pancreas, stomach Neurological – WKS, cerebellar ataxia, peripheral neuropathy, siezures Trauma while intoxicated Mental health

16. What is the nurses role?

17. Alcoholics need not apply

18. 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

19. 1. Taking an alcohol history

20. 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)

21. Alcohol content of what other people drink BEVERAGEAPPROXIMATE ALCOHOL CONTENT (%) UNITS OF ALCOHOL PER CONVENTIONAL MEASURE (1 unit=8g=10mL) BEER AND CIDER i) Ordinary beer31.5 per can (2 per pint) ii) Strong beer4.6 – 6.03 per can (4 per pint) iii) Extra-strong beer7.5 – 9.04 per can (5 per pint) iv) Cider/Strong cider4/63 / 4 per pint WINE (eg table wine)10-148-10 per bottle (2-3 per glass) FORTIFIED WINES (eg sherry, port) 13-1613 per bottle(1 per small standard measure) SPIRITS ( eg whisky, gin, brandy, vodka) 38-4030 per bottle(1 per standard single measure)

22. 1. All patients Document alcohol (& drug use) history Consider Alcohol Problems (Index of suspicion) - alcohol-related disease - alcohol dependence Optimal Responses

23. 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

24. 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?

25. Index of Suspicion Presents intoxicated / smelling of EtOH Isolated raised GGT Alcohol-related disease

26. 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

27. 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

28. Features Autonomic 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

29. Alcohol Withdrawal Scale Patient Name_______DOB _______ Date Time_______________ Perspiration_______________ Tremor_______________ Anxiety_______________ Agitation_______________ Temperature_______________ Hallucinations_______________ Orientation_______________ TOTAL_______________

30. (Parenteral pabrinex) (supportive nursing care) Prevent rather than manage withdrawal Chlordiazepoxide protocol Management of Alcohol Withdrawal

31. 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

32. Responses PatientAction All presentations to ED, and wardsAlcohol, smoking, drug use documented Patient drinking >21 units/week,Brief advice on safe drinking, Alcohol related presentationmonitor 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.

33. Questions

34. Why do heroin addicts receive methadone?

35. 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

36. 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)

37. 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

38. 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

39. Why do People use GBL? 1.Socialising 2.Sex 3.Sleep

40. 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

41. Onset rapid – 3-4 hours Can occur after awaking from OD May 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

42. GBL Withdrawal and Management Initiate high dose diazepam (20mg 2 nd hourly) early. “Usual” dose 70-90 mg day 1 Baclofen 10mg tds Transfer to AAU (more appropriate setting)

43. james.bell@slam.nhs.uk Questions