Alcoholism Update

1. Alcoholism Update Nursing Education Day 2005

2. Epidemiology • Lifetime prevalence between 10-20% • 18.6% of men and 8.4% of women will experience an alcohol dependence diagnosis in their lifetime • 1/3 of children of alcoholics become alcoholics

3. Statistics • Alcohol/medication interactions account for 25% of ER admissions • Among the hospitalized population, 25% to 40% of individuals are being treated for alcohol related complications • > than 12 drinks/wk or > 3 drinks/day puts person at high risk for stomach ulcers, sexual problems, liver disease, brain damage and cancer

4. A Gateway Drug • Of those addicted to marijuana, 36% are alcoholics • Of those addicted to barbituates, 71% are alcoholics • Of those addicted to cocaine, 84% are alcoholics • Of those addicted to opiods, 67% are alcoholics

5. Screening – CAGE Questionaire • Have you felt that you ought to Cut down on your drinking? • Have people Annoyed you by criticizing your drinking? • Have you felt Guilty about your drinking? • Have your ever had a drink upon waking up as an Eye-opener or to steady your nerves?

6. Substance Abuse • Recurrent use resulting in failure to fulfill major role obligation • Recurrent use in physically hazardous situation • Recurrent legal problems • Use despite recurrent or persistent social or interpersonal problem exacerbated by substance

7. Substance Dependence • Tolerance • Withdrawal • Greater than intended use, and longer then intended use • Persistent and unsuccessful effort to cut back or to control • Great deal of time is spent in activities necessary to obtain substance or recover from its effect

8. Substance Dependence (2) • Important social, occupational, or recreational activities given up or reduced • Continued use despite knowledge of persistent or recurrent physical or psychological problems

9. Predisposing Factors • Genetics • Biochemical factors • Developmental influences • Personality factors • Social learning • Conditioning • Cultural/ethnic influences

10. Genetics • Children of alcoholics are 4 times more likely than other children to become alcoholics • Monozygotic twins have twice the rate for concordance of alcoholism compared with dizygotic twins

11. Biochemicals • Hypothesis: alcohol may produce morphine-like substances in the brain leading to addiction

12. Developmental Influences • Anxiety in people fixated at the oral stage may be reduced by taking substances, such as alcohol, by mouth. • Alcohol may serve to increase feelings of power and self-worth in individuals with a punitive superego

13. Personality Factors • Low self-esteem, frequent depression, passivity, the inability to relax or to defer gratification, and the inability to communicate effectively all increase tendency toward addictive behavior. • Substance abuse associated with antisocial personality and depressive response styles

14. Social Learning • Modeling, imitation, and identification on behavior can be observed from early childhood onward. • Family • Peers • Work

15. Conditioning • Alcohol may create a pleasurable experience that encourages the user to repeatedly use it. • The environment is conditioning as well, if the environment is pleasurable the substance use will increase.

16. Culture and Ethnic Influences • Mold attitudes • Influence patterns of consumption • Determines availability of the substance

17. Intervention Can occur during any stage of the addictive illness.

18. Phases of Alcoholic Drinking Phase 1: The pre-alcoholic phase Phase 2: Early alcoholic phase Phase 3: Crucial Phase Phase 4: Chronic Phase

19. Pre-alcoholic Phase • Use of alcohol to relieve the everyday stress and tensions of life • As child may have observed parents or other adults drinking alcohol and enjoying the effects • Child learns alcohol is an acceptable method of coping with stress

20. Early Alcoholic Phase • Begins with blackouts, brief periods of amnesia that occur during or immediately following a period of drinking. • Alcohol is no longer a source of pleasure or relief but is required by the individual to feel normal

21. Crucial Phase • Individual has lost control and physiological dependence is clearly evident. • Binge drinking, lasting from a few hours to several weeks is common • Often angry and aggressive • Drinking is total focus

22. Chronic Phase • Characterized by emotional and physical disintegration • Intoxicated more then sober • Profound helplessness and self-pity • May develop psychosis • Life-threatening physical manifestations may be evident

23. Management Includes: • Assessment • Psychological intervention • Pharmacological intervention • Participation in specific addiction treatment strategies • Monitoring of recovery

24. Assessment: Lab Values • CBC • Glucose • Electrolytes • Nutritional tests • Urinalysis • Chest X-ray • ECG Liver function tests

25. Assessment: Lab Values • AST:ALT ration>1 • Elevated GGT with a GGT:ALP ratio:>2.5

26. Precontemplation Contemplation Preparation Action Maintenance Relapse Stages of Change

27. Precontemplation The patient does not realize that he/she has a problem. The task of the clinician is to raise doubt – increase the patient’s perception of risks and problems with current substance use.

28. Contemplation The patient experiences ambivalence of both reasons to change and status quo. Here the task is to gently tip the balance of ambivalence to evoke reasons to change, and evaluate the risks of not changing and to strengthen the patients sense of self efficacy for change.

29. Preparation The patient is motivated to consider strategies to change but has ambivalence toward specific strategies. The clinician helps the patient to identify the resources that best meet the patient’s needs and offers choices.

30. Action The patient invests energy and time in a specific set of actions and may be easily frustrated. Patients will need support along the way toward change. Here advice and support are welcomed.

31. Maintenance The patient is committed to a set of values to counterbalance the real possibility of relapse. The primary task is to help the patient to identify the risk factors and strategies to prevent relapse.

32. Relapse Although this stage was not initially included in the stages of change, risk of relapse is universal. The primary task at this stage is to restart the process of recovery rather than being stuck. Patients need support and encouragement to renew the process of contemplation and preparation.

33. Withdrawal • In the absence of serious medical conditions alcohol withdrawal is usually transitory and self-limiting. • Pharmacological therapies are indicated to prevent seizures and delirium tremens and to increase compliance with psychosocial forms of addiction treatment.

34. Delirium Tremens • Untreated has a mortality rate of 10-15% • Symptoms of withdrawal can start as early as 5-10 hours in a fragile alcoholic • Usually peak at about 48-72 hours • Individuals who are experiencing severe withdrawal will develop symptoms by day one.

35. Cross Tolerance • Individual with alcohol tolerance will also develop a benzodiazepine tolerance. • Avoid the common error of serious underdosing of benzodiazepines.

36. Basic Rules of Withdrawal • Prevention is good. If you suspect there is withdrawal, treat the patient as if there is withdrawal. • Those with previous withdrawal/DT will have future withdrawal/DT • Never underdose, comfortable sedation is the guideline to needed dose, not how much you gave • Do not mix benzodiazepines. If possible start with one and end with the same one.

37. Objectives: Alcohol Withdrawal Treatment • Relief of subjective symptoms • Prevention or treatment of more serious complications • Preparation for long term rehabilitation with minimal hazard of new dependence problems or direct toxicity related to drug treatment

38. Detecting Withdrawal Severity • Determined by admission assessment • Medical work-up • Administration of an objective rating scale such as the CIWA-A

39. Ideal Drug Profile for ETOH Withdrawal • Rapid onset • Long duration of action • Wide margin of safety • Metabolism not dependent on liver function • Absence of abuse potential

40. Mild: CIWA-A <20 • Accompanied by no prior hx of withdrawal seizures can usually be Tx. Conservatively • Fluids, multivitamins, reassurance, antacids, thiamine

41. Moderate: CIWA – A >20 <25 • Demonstrating signs and symptoms such as authonomic hyperactivity, psychological distress, and perceptual distortions generally require pharmacotherapy

42. Severe: CIWA-A >25 • Diazepam-loading procedure is a safe and effective treatment measure • 10mg diazepam po is administered to the patient every hour until symptoms are suppressed (CIWA-A <10) or the patient becomes sedated.

43. Craving • Phenomenon all addicts can relate to. • Awareness of craving as a symptom of addiction helps users resist the compulsion to relapse. • Psychoeducation includes teaching patients that craving is universal and is not a sign of weakness, and that craving will pass and diminish with time.