Drugs and alcohol

A unit contains 8 g (10mls ) of pure alcohol and is often erroneously defined as a half a pint of beer or a small glass of wine – in fact a 125ml glass of wine with 12% alcohol content actually contains 1.5 units.

Alcohol Screening Tools

CAGE Questionnaire
Have you ever felt you should Cut down?
Have you ever been Annoyed by someone criticising your drinking?
Have you ever felt Guilty about your drinking?
Have you ever had an Eye opener (early morning drink) to steady your nerves/get rid of your hang over?

Score of 2 or more has a high correlation with alcoholism, but less so for hazardous/problem drinking – unless supplemented by additional questions on maximum daily or weekly consumption (CAGE plus two).

WHO Audit C – Alcohol Use Disorders Identification Test

More suitable screening test for excessive drinking at the less severe end of the spectrum
The CAGE questionnaire also asks ‘ever’ questions, rather than focusing on the person’s current alcohol consumption, which can be misleading.

FAST Alcohol Screening Test
Rapid 2 stage 4 item screen.

http://www.aerc.org.uk/documents/pdfs/FAST_Manual_AERC_VERSION.pdf

SIPS

FAST download

www.dundee.ac.uk/gptraining/summative/alcohol2.ppt

http://www.authorstream.com/Presentation/Bernadette-35135-Module-4-Screening-Alcohol-Problems-Social-Work-Settings-Outline-Issues-Accuracy-Ask-Why-Defining-as-Entertainment-ppt-powerpoint/

Alcohol How to Cut Down

Set goals what level of drinking should you keep below?
Who? How many drinks? How often?

Limits
Men No more than 3 standard drinks per day
Women No more than 2 standard drinks per day
Pregnant women No more than 1 standard drinks per week
Men or women with existing disease or physical damage 0 drinks are safe 0 times per week
Men and women with physical dependence on alcohol 0 drinks are safe >0 times per week
Determine action how do you cut down on your drinking to reach these target levels?

Have your alcoholic drink after starting to eat
Quench your thirst with non-alcoholic drinks before having an alcoholic one
Have a non-alcoholic drink before every alcoholic drink
Switch to low-alcohol beer
Take smaller sips
Plan activities or tasks at those times that you usually drink
When bored or stressed have a physical workout instead of drinking
Explore new interests fishing, cinema, social club, exercise
Avoid going to the pub after work
Avoid, or limit whers possible, time with your “heavy” drinking friends
If under social pressure to drink you can always say “my doctor has told me to ease off

Review progress are you keeping on guard and on track?
Questions to ask yourself Tips for keeping you on track

Am I keeping to my goals?
What are the most difficult times?
Am I losing motivation?
Do I need more help?

Every three months, write down how much you have to drink over 1 week.
Try to work out when you find it most difficult to cut down. Plan to avoid these situations or plan activities to help you cope with them. Ask someone close to you to support and help you.
Remind yourself and think carefully of all your reasons for cutting down.
Don’t feel too embarrassed to come back for help.

Department of Primary Health Care, University of Newcastle upon Tyne: last updated Dec 2006

@@@ Alcohol Withdrawal / Detox Regime

Chlordiazepoxide withdrawal schedule – Chlordiazepoxide 5mg tablets x 70 tabs
Day	Total Dose	No. tabs – breakfast, lunch, teatime, bedtime
Day 1	80 mg	4 4 4 4
Day 2	80 mg	4 4 4 4
Day 3	70 mg	4 2 4 4
Day 4	50 mg	2 2 2 4
Day 5	35 mg	2 1 1 3
Day 6	25 mg	1 1 1 2
Day 7	10 mg	1 0 0 1

Drugs are required to replace alcohol during withdrawal in order to prevent delirium tremens and fits:
chlordiazepoxide
chlordiazepoxide is the drug of choice (1). Diazepam is an alternative
chlordiazepoxide is the preferred benzodiazepine for community-based detoxification in view of its long half-life, and also because there is less likelihood of ‘diversion’ into the illicit drug scene (2) diazepam is often a drug of abuse

the following chlordiazepoxide regime is recommended (1) though the dose level and length of treatment will depend on the severity of alcohol dependence and individual patient factors (e.g. weight, sex, liver function)
Day 1 &2 20-30mg chlordiazepoxide QDS
Day 3 & 4 15mg chlordiazepoxide QDS
Day 5 10mg chlordiazepoxide QDS
Day 6 10mg chlordiazepoxide BD
Day 7 10mg chlordiazepoxide nocte

Withdrawal of alcohol in less severe cases of dependency may be managed at home. For the first five days, the patient’s temperature, pulse, blood pressure, hydration and level of consciousness need to be assessed daily. If there is deterioration, delirium tremens may be developing and the patient should then be admitted to a detoxification unit.
Daily visits by a district nurse or CPN may be needed for physical and mental state assessment and to administer medication.
The support of family, friends and care workers is essential. Groups such as Alcoholics Anonymous to support the patient, Al-Anon to support the spouse and Al-Ateen to support teenage children may be useful.

dispensing should be daily, or involve the support of family members to prevent any risk of misuse or overdose. Confirm abstinence by checking for alcohol on the breath, or using a saliva test or breathalyser for three to four days
if possible, see the patient daily for the first five days and again after detoxification has finished. These do not have to be long consultations but they will allow the early detection of complications and encourage the patient to continue. Usually there will be a noticeable improvement in the patient as the detoxification progresses where there is significant liver disease, diazepam and chlordiazepoxide metabolism is impaired, and it imay be necessary to consider a benzodiazepine that is not metabolised by the liver e.g. oxazepam

Alcohol Misuse Drugs to Prevent Relapse

Disulfiram
disulfiram blocks the hepatic oxidation of alcohol by aldehyde dehydrogenase (ALDH) causing an accumulation of acetaldehyde after drinking – resulting in abdominal colic, flushing, anxiety, dizziness, tachycardia, vomiting and headache. Symptoms start 5-15 minutes after drinking alcohol and last for several hours. Note that the intensity of the reaction is dependent on the individual, the disulfiram dose and the alcohol intake – if large doses of alcohol are consumed whilst receiving disulfiram treatment, collapse, cardiac arrhythmias and even death can occur
Liver function tests should be checked before commencement of and at regular intervals throughout treatment disulfiram treatment should be witheld if liver enzymes are elevated ten or more times than normal
disulfiram should be used with caution in patients with diabetes, epilepsy and hypercholesterolaemia and avoided in patients with seriously impaired cardiac, respiratory, hepatic psychosis or cerebral function.

Acamprosate
Acamprosate iacts on the GABA/glutamate system associated with alcohol dependence thus leading to a reduction in the risk of relapse during the postwithdrawal period
not metabolised by the liver and has no interaction with alcohol.
treatment option for the prevention of relapse following previous alcohol abuse
first drug licensed for the prevention of relapse that actually reduces desire to drink
should be initiated as soon as possible after abstinence has been achieved
should be used in conjunction with specialist alcohol counselling
does not have a depressive effect
should be continued if the patient relapses however continued alcohol abuse negates the therapeutic benefit of treatment with acamprosate
contra-indications include severe hepatic and renal impairment; also contra-indicated in pregnancy and breast-feeding
BZD Withdrawal

Naltrexone and Opiate Detox
Naltrexone
recommended as a treatment option in highly motivated detoxified (at least 7-10) days opioid-dependent people
should be given as part of a programme of supportive care
effectiveness of naltrexone in preventing opioid misuse in people being treated should be reviewed regularly. Discontinuation of naltrexone treatment should be considered if there is evidence of such misuse
Liver function tests are recommended before and during naltrexone treatment to check for liver impairment
naltrexone is associated with opioid withdrawal symptoms if people are opioid dependent