ALCOHOL, DRUGS AND HOSPITALSJames Bell

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

Why do people use drugs?

Drug use is normal behaviour

Why do people use drugs?

Who develops drug problems?

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

Alcohol and hospitals

Alcoholics need not apply

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

What is the nurses role?

Alcoholics need not apply

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

1. Taking an alcohol history

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.

Questions

Why do heroin addicts receive methadone?

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

Why do People use GBL?

1. Socialising

2. Sex

3. Sleep

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)

james.bell@slam.nhs.uk

Questions