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Identification
CAGE questionnaire Have you ever thought that you should Cut down on your drinking
Has anyone Annoyed you by commenting on the amount you drink
Have you ever felt Guilty about the amount you drink
Do you ever have an Eye opener
Cycle of change
1. Anger at mentioning alcoholDon’t pursue topic
2. Would like to change but not just yetGive written information about how to seek help
3. Wants to change nowUse motivational interviewing technique to start change
4. Already started to changeReinforce and support change
Motivational interviewing
People believe what they hear themselves say
Empathic interviewing style Open ended questions Reflective listening Get on their wavelength
Feedback about risk Agree factual information about personal
harm or impairment Balance sheet of pro’s and cons of
changing /not changing
Motivational interviewing People believe what they hear
themselves say Roll with resistance
Avoid confrontation Arguments about terms such as alcoholic
are fruitless particularly in the early stages Support self efficacy
Patient takes responsibility for achieving goals
Choosing from menu of options Encourage belief that change is possible
Motivational interviewing
People believe what they hear themselves say Reinforce self motivate patientsRecognition of harm causedDesire to changeFeasibility of change
Withdrawal symptoms
Common features on stopping alcohol Anxiety and agitation Tachycardia Sweating Tremor of extended hands, tongue or
eyelids Nausea and vomiting Insomnia Withdrawal fits Confusion hallucinations
Withdrawal symptoms
Should be mild if Alcohol free at consultation Male drinking < 15units/day Female drinking < 10 units/day
Units of Alcohol 1 ordinary glass of wine 9/bottle ½ pint low strength beer 1 standard pub short
Withdrawal symptoms
Management – mild symptoms Rest Relaxation Reassurance that they will pass in a few
days Explanation – they are evidence of that
the brain has adapted to living in an alcoholic environment and will take time to readjust to one that is alcohol free
Withdrawal symptoms
Need for specialist or hospital referral Confusion Hallucinations History of fits or epilepsy Risk of suicide Failed home detox Poor nutrition Unsupportive home environment Acute physical or psychiatric illness Any symptoms of encepalopathy
Wernicke’s encepalopathy
Signs Confusion Ataxia Opthalmoplegia Nystagmus Coma Hypotension Hypothermia Any unexplained neuro signs during
withdrawal
Wernicke’s encepalopathy
Require urgent specialist assessment
Urgent treatment with parentral thiamine (Pabrinex IM )
Drug treatment
Drug of choice for withdrawal are benzodiazepines Can induce temporary problems with
cognition and recall Are addictive if taken over time Detox with benzos should not be
continued for more than 7 days Start with high dose chlordiazepoxide
120mg/day or diazepam 20mg/day
Other support
Patients and family should be advised To stay off work Not drive Rest Drink plenty of fluids – fruit juice rather
than stimulants such as cafeine Abstain from alcohol
Other support
Community nurse of GP should visit daily to Monitor progress Review drugs Assess mental state and vital signs Breathalyse for alcohol if possible Patient may think they can now handle
alcohol must make it clear that drinking must not be resumed
Vitamins
If well nourished with moderate alcohol dependence no vitamins required
If under nourished or frequent relapse or self neglect
Then 200-300mg thiamine a day for 2-3 months will help minimise risk to brain and peripheral nervous system
May need parental admin during early stages of detox
Preventing relapse
Triggers to relapse Environment
Availability Pub atmosphere
Custom Always drinks at certain times, occasions
and situations Interpersonal
Stress conflicts
Preventing relapse
Triggers Intrapsychic
Expectations Anxiety Social phobias Depression or elation
Overconfidence Feeling good I have got over my drinking problem I can take some alcohol again
Preventing relapse
Drinking diary Balance sheet of good and bad
consequences of continued drinking Patient should set own goals Monitor progress Identify ways of dealing with triggers
to relapse
Preventing relapse
Pharmacotherapy Disulfiram
Blocks metabolism of alcohol flooding the body with toxic acetaldehyde which causes flushing, palpitations, nausea, faintness and even collapse
Start with 200mg/day can be increased to 400mg
Contra indicated with liver disease, cardiovascular disorders, pregnant women, suicidal patients or those who are cognitively impaired
Only effective if use is supervised
Preventing relapse
Pharmacotherapy Acamprosate
Helpful adjunct to psychological therapies.
Start as soon as abstinence is achieved
Can be continued during relapsecan be continued for 1 year
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