Alcohol and Prescription Drug Problems in Family Medicine

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Alcohol and Prescription Drug Problems in Family
Medicine

• A Project CREATE Module

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Outline

• Alcohol problems screening, assessment
• Advice, referral and counselling
• Treatment of alcohol withdrawal
• Principles of opioid prescribing
• Principles of benzodiazepine prescribing
• Drug-seeking behaviours

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Alcohol Problems

• Prevalence
• Screening
• Diagnosis
• Assessment

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Alcohol Problems Common, Serious, Often Missed

• 14 of Ontario adults have 15-35 drinks per week
  3.3 are alcohol-dependent
• 7.5 billion cost, 6701 deaths, 186,257
  person-years life lost (1992)
• Physicians are poor at identifying patients with
  alcohol dependence
• Most likely to miss women, elderly, high
  socio-economic status

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ALCOHOLLow-risk Drinking Guidelines

• 0 consumption for special populations (e.g.,
  pregnant women)
• 2 drinks maximum on any day for all
• 9 drinks maximum for women weekly
• 14 drinks maximum for men weekly

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Diagnostic Categories

• Alcohol problems lie along a continuum
• Abstinence
• Low-risk drinking
• At-risk drinking
• Problem drinking
• Alcohol dependence

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CATEGORY OF ALCOHOL USE
Abstinence and Low-Risk Drinking
At-Risk and Problem Drinking
Alcohol Dependence
Specialized Treatment
Brief Intervention
Primary Prevention
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Problem Drinking

• Drinks above recommended guidelines
• May have alcohol-related psychological, social or
  physical problems
• Does not have features of established alcohol
  dependence
• Far more common than alcohol dependence

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Alcohol Dependence

• Meets DSM-IV criteria for dependence
• Often physically dependent (tolerant, withdrawal
  symptoms)
• Preoccupation with alcohol, neglect of social
  responsibilities due to alcohol, continuing to
  drink despite severe social or physical
  consequences

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Screening for Alcohol Problems
Quantity-Frequency

• Ask ALL patients (women, elderly most likely
  missed)
• Ask daily or weekly amount
• Ask about MAXIMUM consumption on any one day in
  past month
• Convert responses to standard drinks 12 oz.
  beer bottle, 5 oz. glass of wine, 1 1/2 oz.
  liquor

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CAGE Questionnaire

• Have you ever felt you ought to Cut down on your
  drinking?
• Have people Annoyed you by criticizing your
  drinking?
• Have you felt bad or Guilty about your drinking?
• Have you ever had a drink first thing in the
  morning to steady your nerves or get rid of a
  hangover (Eye-opener)?

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Laboratory Markers

• Poor screening method due to low sensitivity and
  specificity
• Most sensitive is elevated GGT (35-50)
• Other causes microsomal inducing agents
  (phenobarbital, phenytoin), obstructive liver
  disease, hepatitis, diabetes, obesity
• Average half-life of 26 days can take 4 months
  to return to normal
• Elevated MCV less sensitive (35-40)

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Common Presentations ofHeavy Drinking

• Trauma
• GI symptoms (gastritis, nonspecific dyspepsia,
  recurrent diarrhea)
• Hypertension
• Depression, anxiety
• Insomnia
• Social and family dysfunction
• Sexual problems

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Assessment of Patients With a Suspected Drinking
Problem

• Withdrawal symptoms, social and physical
  consequences of alcohol use
• Previous treatment attempts
• Other drugs (benzodiazepines, opioids,
  over-the-counter medications, street drugs)
• Depression, anxiety

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Assessment of Patients With a Suspected Drinking
Problem

• Social situation, woman abuse, child
  abuse/neglect
• Current readiness to change
• Physical exam

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Comparison of Problem Drinking and Alcohol
Dependence
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PROBLEM DRINKING

• Effectiveness of Treatment for Alcohol Problems
• Brief Advice for the Problem Drinker

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Advice and Referral for Alcohol ProblemsWhy
Physicians Dont Do It

• Physician beliefs
• Its not the job of a doctor.
• Its a self-inflicted illness.
• Theres no point to doing this.
• Physician experiences
• Intoxicated patients can be loud and abusive.
• Patients are often non-compliant.
• Lack of physician training

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Effectiveness of MD Advice toProblem Drinkers

• Randomized trials have shown that brief advice by
  a physician with problem drinkers reduces alcohol
  consumption, hospital admission rates and
  emergency room visits
• Advice ranged from a few minutes to 1-2
  counselling sessions
• Family physicians who gave advice were not
  addiction experts

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Brief Advice for Problem Drinkers

• Advise patients regarding low-risk guidelines
• ARF
• 2 drinks/day (men and women)
• 9 drinks/week (women), 14 drinks/week (men)
• ARAI
• 3 drinks/day (women)
• 4 drinks/day (men)
• 12 drinks/week (men and women)

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Advice to Problem Drinkers

• Health effects of alcohol consumption
• Where patients consumption fits within Canadian
  norms
• Contraindications to alcoholconsumption

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Estimated Distribution of ConsumptionOntario,
1988-1989
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Advice to Problem Drinkers

• Assist the patient in committing to a drinking
  goal (ideally within low-risk levels)
• Assist the patient in avoiding intoxication
• Have no more than one standard drink/hour
• Start drinking later in evening
• Sip drinks, dont gulp
• Avoid drinking on empty stomach
• Alternate alcoholic with non-alcoholic drinks

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Brief Interventions With Problem Drinkers

• Provide self-help literature
• Have patient keep drinking diary
• Order GGT and MCV at baseline and follow-up
• Have regular follow-up visits
• Consider referral for more intensive treatment if
  brief advice fails

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ALCOHOL DEPENDENCE

• Alcohol Withdrawal
• AA, Treatment Programs
• Motivational Interviewing
• Long-term Management

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Alcohol DependenceManagement

• Set ABSTINENT treatment goal
• Treat withdrawal
• Encourage patient to join AA or other self-help
  group
• Refer to formal treatment program
• Use pharmacotherapy when indicated

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Effectiveness of Advice and Treatment for Alcohol
Dependence

• Many patients will accept referral to formal
  alcohol and drug treatment programs
• Treatment programs work
• 25-50 are abstinent one year post-treatment
• Treatment programs are cost-effective
• Matched case-control study of alcohol-dependent
  patients 300 reduction in hospital costs in
  treated group

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Alcohol Withdrawal

• Develops 6 to 48 hours after last drink
• Can last up to 7 days
• Classified as minor, intermediate or major
• Undetected, undertreated withdrawal is a barrier
  to recovery
• Ask all patients about withdrawal symptoms
• Past history predicts future episodes

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Alcohol Withdrawal

• Minor starts 6-48 hours, lasts up to 7 days
• Tremor, sweating, tachycardia, vomiting
• Intermediate Seizures, arrhythmias, hallucinosis
• Major (delirium tremens) Starts day 3-5 of
  severe, untreated withdrawal
• More common in medically ill alcoholics
• Confusion, hallucinations, autonomic hyperactivity

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Diazepam Loading Technique

• Diazepam 20 mg PO per hour until symptoms abate
• Long half-life covers duration of withdrawal - no
  need for take-home doses
• If history of withdrawal seizures 20 mg PO per
  hour for at least three doses
• Admit to hospital if more than 60-80 mg needed,
  major withdrawal, uncontrolled
  seizures/arrhythmias, medically ill

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Diazepam Loading Precautions

• Do not give diazepam if BAL gt 0.15
• Will not prevent seizures in patients taking
  daily high-dose sedatives
• Give lorazepam if elderly, debilitated, low serum
  albumin, severe liver disease, respiratory
  failure or severe asthma
• Give IV diazepam if cant take orally
• Give thiamine 100 mg IM dont give IV glucose

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Alcohol DependenceTypes of Treatment Programs

• Inpatient (residential)
• Outpatient day or outpatient treatment
• Halfway houses 6 months or longer
• Mutual aid groups AA, Women for Sobriety
• Family Al-Anon for familymembers

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Role of Alcoholics Anonymous

• Based on the 12 Steps
• Open and closed meetings
• Each member encouraged to find a sponsor
• Can reduce feelings of uniqueness /isolation
• Can provide information, give hope for recovery,
  provide assistance when setbacks occur
• Attendance at AA can be facilitated by MD

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Aversive Medication Disulfiram (Antabuse)

• Inhibits acetaldehyde dehydrogenase
• Causes flushing, palpitations, nausea and
  lightheadedness if alcohol consumed
• Sometimes delays time to relapse by preventing
  impulsive drinking
• Warn patient not to drink within 7 days of last
  dose
• Should never be used as a sole treatment

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Opioid Antagonist TherapyNaltrexone (ReVia)

• Competitive opioid antagonist
• Blocks alcohol-induced endorphin release
• Decreases cravings, mean drinking days and
  relapse rates in alcohol-dependent patients
• Should be prescribed with formal treatment
• Renders prescription opioids ineffective,
  triggers withdrawal in opioid-dependent patients

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Principles of Motivational Interviewing

• Patients are in different stages of readiness to
  change
• precontemplation, contemplation, action,
  maintenance, relapse
• Most patients are ambivalent, weighing the pros
  and cons of changing v. not changing
• Encouraging patients to explore their ambivalence
  may lead to resolution and commitment to change

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Stages of ChangePrecontemplation

• Patients dont see drinking as a problem
• Characterized by reluctance, rebellion,
  resistance, rationalization
• Physician strategy
• Discuss the role alcohol plays in their life
• Provide information

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Stages of ChangeContemplation

• Patient is ambivalent about change - feels
  drinking causes problems but also has benefits
• Physician strategy
• Ask patient to discuss pros and cons of changing
  v. not changing
• Focus on their concerns about their drinking, and
  their reasons for change

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Stages of ChangeAction

• Patient is committed to change
• Physician strategy
• Elicit practical goals and strategies
• Focus on success
• Present a menu of treatment options
• Emphasize You are the best judge of what will be
  best for you.

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Techniques of Motivational Interviewing
Empathic Listening

• People are more likely to respond to a suggestion
  if they feel they are understood
• Empathic listening techniques
• Open-ended questions
• Reflection
• Summary statements

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Motivational InterviewingMinimizing Resistance

• Patient resistance is increased by
• Direct advice, e.g., You should do this
• Arguing - forcing ones idea upon a patient
• Labelling, e.g., You are an alcoholic.
• Moving too fast - overestimating patients
  readiness to change

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Working With the Alcohol-dependent Patient

• Present the diagnosis, but avoid arguing and
  negative labels
• Discuss your concerns about his/her health and
  social situation
• Explain that the illness is treatable and you can
  help
• Review treatment options negotiate a plan

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Working With the Alcohol-dependent Patient

• Involve the family consider their needs
• Use motivational enhancement techniques
• Avoid sedatives and opioids
• Treat psychiatric comorbidity
• Address psychosocial problems

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Helping the Patient in Recovery

• Encourage patient to attend aftercare, mutual aid
  groups, contact with sponsor
• Have regular follow-up recognize dry-dates and
  recovery anniversaries
• Identify high-risk situations and cravings
• Encourage a balanced life-style
• Have a plan to interrupt a lapse reframe a
  relapse as a learning experience

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SPECIAL POPULATIONS

• Women
• Elderly
• Physicians

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Women and Alcohol

• Greater risk for liver disease
• Less likely to be identified
• Shame, stigma
• Physician stereotypes
• Risk factors
• Multiple social roles
• History of abuse a major risk factor
• Untreated anxiety disorders or depression

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Barriers to Entering Treatment

• Fear of consequences
• Role responsibilities
• Lack of support from partner, family

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Barriers to Entering Treatment

• Most treatment participants are male
• Difficulty disclosing personal issues in group
• Treatments emphasis on admitting powerlessness,
  harm

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Elderly

• Neurological complications
• More sensitive to effects of alcohol
• More alcohol-drug interactions
• Less likely to be identified
• Fewer treatment options

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Other Populations

• Language barriers
• Cultural attitudes towards drinking
• Concurrent disorders
• Other populations (e.g., youth, gays and lesbians)

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Physicians

• Prevalence similar to general population
• Greater access to potent opioids
• More likely to self-medicate
• Physicians lifestyle may contribute
• Barriers to entering treatment
• Reluctance to enter sick role
• Fear of consequences for practice, license
• Colleagues unwilling to intervene

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Physicians

• Good prognosis once enters treatment
• Treatment
• Inpatient, outpatient programs
• AA, Cadeuceus group
• Monitoring
• OMA, CPSO support

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OPIOIDS AND CHRONIC PAIN

• Principles of Opioid Prescribing
• Opioid Dependence

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Role of Opioids in Treatment of Chronic Pain

• Nociceptive pain
• 1st line NSAIDs, acetaminophen, then opioids
• Neuropathic pain
• 1st line tricyclics, anticonvulsants opioids
  less effective
• Visceral pain, migraine
• Limited role for opioids
• Fibromyalgia, tension headache
• No role for opioids

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Before Long-term Prescribing of Opioids...

• Chronic pain helped by
• Cognitive behavioural treatment
• Relaxation exercises, deep breathing
• Supportive counselling
• Lifestyle changes

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Opioid Prescribing in Chronic Pain

• Modest effectiveness in chronic pain
• Give comprehensive trial of non-narcotic
  alternatives first
• Use non-pharmacologic methods
• Focus on improved functioning, not complete pain
  relief

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Opioid Prescribing Precautions

• Titrate cautiously especially in those at risk
  (e.g., elderly, COPD)
• Avoid benzodiazepines and other sedating drugs if
  possible
• Warn patients about combining with alcohol
• Warn about driving

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Screening for Opioid Dependence

• Those with history of alcohol/drug dependence are
  at risk
• Use opioids with caution if
• Positive CAGE
• Drinks gt 14/week (men), 9/week (women), 2 per
  drinking day
• Regular use of street drugs
• Previous heavy prescription drug use

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Opioid Titration

• Titrate slowly using pain rating scale
• Goal Modest pain relief, /- improved mood,
  functioning. Opioids rarely eliminate chronic
  pain!
• Discontinue if no pain relief, major adverse
  effects or interference with function

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Opioids Prescribing Principles

• Start with acetaminophen/codeine
• Switch to long-acting codeine or oxycodone
  preparations
• Switch to morphine if necessary

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Opioids Prescribing Principles

• Convert to long-acting morphine
• More consistent pain relief, less reinforcing
  effects
• Be cautious about prescribing doses above 300 mg
  per day
• Avoid short-acting opioids with high dependence
  liability
• Percocet?, Dilaudid?, parenteral opioids

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Safe Prescribing

• Obtain informed consent mention risk of
  dependence
• Assess patient frequently chart effectiveness,
  adverse effects, changes in functional status
• Keep a narcotic prescription flow-chart
• Do not dispense large amounts

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Safe Prescribing

• Consult when unsure
• Tamper-proof your prescriptions
• Double lines through unused scripts
• Write in words and numbers
• Keep scripts in lab coat pocket

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Safe Prescribing

• Use a treatment contract
• Only one prescriber
• Compliance with treatment program
• No early dispensing
• Consequences for breaking contract

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Opioid Dependence in Chronic Pain Patients

• Opioid dependence is a DSM-IV diagnosis
• Dependence is not common
• Tolerance to analgesic effects develops slowly
• Patients often remain on same dose for years
• Most do not experience euphoria
• With dependence, opioid is used for psychic
  effects
• Tolerance and withdrawal develop quickly

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Behaviours Suggesting Opioid Dependence

• Running out of the drug early
• Double-doctoring, prescription forgery
• Unauthorized drugs in the urine drug screen
• Drowsiness, nodding off
• Doses far in excess of whats normally required
  for patients with similar condition
• Refusal to try other treatments

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Symptoms of Opioid Withdrawal

• Anxiety, insomnia, drug-craving, myalgia,
  flu-like symptoms lasting from five days to
  several weeks
• Safe except in pregnancy because of risk of
  premature labour
• During pregnancy methadone maintenance is
  recommended

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Management of Opioid Withdrawal

• Treat with clonidine 0.1 mg qid
• Or slowly taper with a long-acting opioid (e.g.,
  MS Contin?)

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Management of Opioid Dependence

• Involve pain specialist, addiction specialist
• Have plan for treating withdrawal
• Use self-help groups, treatment program
• Use alternative treatments for pain/anxiety
• Methadone maintenance an option for opioid
  dependence
• When prescribing, use firm treatment contract,
  frequent assessment, dispense small amounts

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BENZODIAZEPINES

• Prescribing Principles
• Tapering

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Benzodiazepines and Anxiety

• Before prescribing, assess to determine cause of
  anxiety
• Psychiatric situational anxiety, generalized
  anxiety disorder, depression, panic disorder,
  obsessive-compulsive disorder, early dementia
• Organic alcohol/drug abuse, hyperthyroidism,
  cardiorespiratory conditions

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Use Alternatives First

• Supportive counselling, lifestyle changes
• Cognitive/behavioural therapies
• Progressive muscle relaxation, meditation
• Counselling for psychosocial issues
• Buspirone
• Selective Serotonin Reuptake Inhibitors

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BZD Prescribing Principles

• Screen for substance abuse
• Use treatment contract, prescribe for short
  periods
• Do not combine with other sedating drugs

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BZD Prescribing Principles

• Warn about driving risks
• Avoid long-acting BZD in elderly falls, hip
  fractures, motor vehicle accidents
• Use with caution if
• COPD, sleep apnea
• Psychiatric disorders (depression)
• Prescribe for no longer than 3 weeks

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Benzodiazepine Withdrawal

• Can occur even with therapeutic doses
• Two groups of symptoms
• Anxiety-related symptoms (e.g., irritability)
• Neurologic (e.g., tinnitus, blurry vision,
  dysperceptions, depersonalization)
• Onset 1-4 days, may last weeks or months
• Abrupt cessation of doses above 50 mg
  diazepam/day or the equivalent can cause
  seizures, psychosis or delirium

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Benzodiazepine Tapering

• Try slowly tapering patients on long-term
  benzodiazepines. Possible benefits
• More alert, energetic better able to make
  positive life changes do not need drug anymore
  avoid future adverse effects
• Wait until a treatment plan is in place
• Provide regular support
• Stop or reverse taper if patient becomes worse

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Benzodiazepines Outpatient Tapering

• Convert to equivalent dose of diazepam in divided
  doses
• Taper over 6-12 weeks by 2-5 mg diazepam per week
  
• Adjust initial dose and rate of taper according
  to symptoms
• May need to slow taper at doses below 20 mg

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DRUG SEEKING
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Drug Seekers

• Make false claims of pain or distress
• Gravitate towards clinical services with a high
  volume of new patients
• Often dependent on licit or illicit opiates
• May be dependent on cocaine or other drugs
• A subset have true organic pain
• May be trafficking in narcotics

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Drug Seeking Clinical Features

• Ask for drug of choice by name
• Refuse other therapeutic options
• Difficult to confirm story
• Pressures doctor through anger, tears, bargaining

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Drug Seeking Management

• Use general policy statements
• Only prescribe if you believe the patient might
  be on the level
• Dont make decisions based on stereotypes
• Try to confirm the patients story

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Drug Seeking Management

• Ask if they have received a narcotic within the
  past 30 days
• Offer alternative treatment
• Guard your prescription pad carefully

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Drug Seeking Management

• Ask if they feel they have a drug problem
• If they admit to a drug problem
• Refer them for treatment
• Offer non-narcotic treatment of withdrawal
• Dont taper with opioids

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