Treatment for alcohol related problems
http://www.100md.com
《英国医生杂志》
Introduction
When hazardous or harmful drinking is first identified in primary care or the hospital setting, patients should be offered brief intervention. This consists of 10 minutes of discussion and explanation, provision of a self-help booklet, and the offer of a further appointment in one or two weeks. Its cost effectiveness has been proved, although time may have to be set aside rather than trying to undertake intervention within normal practice. Training and employing a member of staff for the purpose is worth consideration.
Motivational interviewing
The value of motivational interviewing is proved. This essentially is an empathic, non-confrontational approach in which the doctor helps the patient identify his or her own reasons for change and strategies for achieving realistic goals. Essential components include sustaining commitment over time, involving the family when possible, acknowledging achievements, and dealing promptly with lapses. A patient's motivation to change his or her way of life fluctuates according to mood and circumstance, and patient and doctor can feel deflated by early setbacks.
Motivational interviewing
The primary care team is ideally suited to provide long term support. Barriers to change need to be identified: some patients will have few barriers; others will have serious impediments that need to be dealt with.
Dependence and detoxification
Some patients will find it hard to cut down or stop drinking because they experience withdrawal symptoms. At first, these may not be recognised for what they are. Patients may describe feeling nervous without a drink or not being able to function effectively until the first drink of the day. Other features in patients who are physically dependent will provide supportive evidence. They vary in severity.
Alcohol withdrawal syndrome
Mild symptoms can be dealt with by rest, relaxation, and reassurance. An explanation that withdrawal symptoms are evidence that the brain has adapted to living in an alcoholic environment and will take time to adjust to one that is alcohol free is helpful. Patients find it reassuring to know that symptoms, however unpleasant, will pass in a few days. This approach is often enough when patients are alcohol free at interview and report drinking < 15 units a day in men and < 10 units a day in women without recent withdrawal symptoms or recent drinking to relieve alcohol withdrawal.
When dependence is more advanced, the discomfort of withdrawal may necessitate medical detoxification. In most cases, this can be done at home, but patients whose symptoms are very severe and who have other prominent physical, psychological, and social factors, need referral for specialist treatment in hospital.
Factors indicating need for specialist or hospital referral
Drug treatment
Benzodiazepines are the drug of choice for managing withdrawal symptoms. Remember that they can induce temporary difficulties in cognition and recall. They are addictive if taken over time, and detoxification with benzodiazepines should not be continued for more than seven days. It is sensible to start with a high daily dose, such as 120 mg chlordiazepoxide or 20 mg diazepam on the first day, and then reduce the dose. After the third day, the dose should have been reduced by at least 25%. Details of the drug regimen should be adjusted to the patient's condition.
This article is adapted from the 4th edition of the ABC of Alcohol, which will be available in February
Other support
Drug treatment is only one part of the treatment for withdrawal. Patients and families should receive a careful explanation and should be advised to stay off work, not drive, rest, and drink plenty of fluids (fruit juice rather than stimulants such as coffee). The need to abstain from all alcohol should be made clear. Ideally, a community nurse or general practitioner should visit daily to monitor progress, review drugs, assess mental state, and vital signs, and, if possible, breathalyse for alcohol. Withdrawal symptoms usually resolve in 4-6 days, after which time patients feel much better and optimistic about the future. They may believe they can now handle alcohol, but it needs to be made clear to patients and carers that on no account should drinking (however little) be resumed. The visiting health professional is well placed to establish a therapeutic alliance for the future and reinforce the need for continued abstinence.
Detoxification regimen
Vitamins
No clear evidence shows that oral vitamins are needed for well nourished people with moderate alcohol dependence. In patients who are undernourished and have a history of frequent relapse and self neglect, however, 200-300 mg thiamine a day over three months or longer will help minimise the risk of damage to the brain and peripheral nervous system. Oral vitamins are absorbed poorly during the early stages of detoxification, so parenteral thiamine may be needed. If the patient is suspected to have or be developing Wernicke's encephalopathy, urgent treatment in hospital with parenteral thiamine is needed.
Detoxification—daily check
Other drugs are rarely necessary. Antacids will help relieve stomach pains. Anticonvulsants are of little value in preventing withdrawal fits, and the management of alcohol dependent people with established epilepsy is best supervised by a specialist clinic. Antidepressants are not indicated at this stage in treatment, and antipsychotics are needed rarely.
Wernicke's encephalopathy
Preventing relapse
The drinker will need to devise strategies to cope with life without recourse to alcohol or with controlled drinking. Some people will find it relatively easy to change this habit; this is often most true of those who identified the problem early and have not developed severe physical, social, and psychological problems.
Triggers to relapse
A drinking diary and a balance sheet of the good and bad consequences of continued drinking, which are often used in the initial assessment, are useful tools throughout follow up, and they can be used to set goals and monitor progress. Patients are encouraged to set their own goals and identify ways of dealing with triggers to relapse. If possible, involve the family in the plan and encourage persistence, even in the face of relapses. Sometimes major barriers to change that are not responding to motivational approaches will be obvious, and more specialist help will be required.
Many problem drinkers risk becoming dependent on benzodiazepines, which have been initiated over a series of failed detoxification episodes.
Pharmacotherapy
Disulfiram
Disulfiram is a well established drug that acts as a deterrent to drinking by blocking the metabolism of alcohol and thus flooding the body with the toxic substance acetaldehyde. This produces flushing, palpitations, nausea, faintness, and in some cases collapse. Very rarely the consequences are serious or even fatal.
Problems most often occur when high doses are taken. An initial dose of 200 mg a day, if tolerated, can be increased after a few days to 400 mg; eventually a supervised dose of 400 mg two or three times a week is usually enough. Disulfiram should not be given to patients with serious active liver disease or cardiovascular disorders, to pregnant women, or patients who are suicidal or cognitively impaired. The action should be explained carefully to patients and their families. Patients should carry explanatory leaflets and a card explaining the actions of the drug.
St Martin, patron saint of alcoholics and alcoholism
The efficacy of disulfiram has been shown only when its use is supervised—for instance, by relatives or by clinic, primary care, or occupational health staff. Disulfiram interferes with the metabolism of other drugs, most notably tricyclic antidepressants, monoamine oxidase inhibitors, heparin, and some anticonvulsants. Drowsiness is noted by some users. Hepatotoxicity is a recognised risk, and regular monitoring of liver function in the early months of treatment is advisable.
Acamprosate
Acamprosate has proved helpful as an adjunct to psychological therapies. It should be started as soon as abstinence is achieved and can be continued during a relapse. If the patient makes good progress, it can be continued for one year. The dose is 666 mg three times daily for patients aged 18-65 years who weigh 60 kg or more. Patients who weigh less than 60 kg should take 666 mg at breakfast, 333 mg at midday, and 333 mg at night. Side effects are rare and are mostly mild gastric upsets.
Naltrexone also improves outcome and reduces the severity of relapse, but it is not yet licensed for regular use in the United Kingdom.
Referral
Referral
Referral to another agency should be timed carefully. Referral should not be too early because the patient may feel rejected; neither should it be too late, when the patient and family have become despondent or further damage has occurred. At the time of referral, a further follow up appointment should be made to find out whether the patient attended and how they got on. The dropout rate at the point of referral is high.
For people with established alcohol dependency, Alcoholics Anonymous is a valuable resource. It is best to make a personal introduction if possible.
Drug treatments should always be accompanied by psychological support and therapy aimed at attaining a longer term change of lifestyle that is essentially drug free
Further reading
? Edwards G, Marshall EJ, Cook CCH. The treatment of drinking problems. Cambridge: Cambridge University Press, 2003
? Freemantle N, Paramjit G, Godfrey C, Long A, Richards C, Sheldon T, et al. Brief interventions and alcohol use: are brief interventions effective in reducing harm associated with alcohol consumption? Effective Health Care 1993;7: 1-13
? Fuller RK, Gordis E. Does disulfiram have a role in alcoholism treatment today? Addiction 2004;99: 21-4
? Garbutt J, West S, Carey T, Lohr E, Crews F. Pharmacological treatment of alcohol dependence: a review of the evidence. JAMA 1999;281: 1318-25
? Miller W, Wilbourne P. Mesa grande: a methodological analysis of treatments for alcohol use disorders. Addiction 2002;97: 265-77
? Slattery J, Chick J, Cochrane M, Craig J, Godfrey C, Kohli H, et al. Prevention of relapse in alcohol dependence. NHS Scotland: Health Technology Board for Scotland, 2002
Competing interests: None declared.
Bruce Ritson is a former consultant psychiatrist, Royal Edinburgh Hospital, Edinburgh EH10 5HD (drbruceritson@zoom.co.uk)
The ABC of Alcohol is edited by Alex Paton, retired consultant physician, Oxfordshire (PatonAlex@aol.com) and Robin Touquet, consultant in accident and emergency medicine, St Mary's Hospital, London (R.Touquet@imperial.ac.uk).
The photograph of people drinking is by Martin Parr/Magnum Photos. The picture of St Martin is with permission of the Bridgeman Art Library.(Bruce Ritson)
When hazardous or harmful drinking is first identified in primary care or the hospital setting, patients should be offered brief intervention. This consists of 10 minutes of discussion and explanation, provision of a self-help booklet, and the offer of a further appointment in one or two weeks. Its cost effectiveness has been proved, although time may have to be set aside rather than trying to undertake intervention within normal practice. Training and employing a member of staff for the purpose is worth consideration.
Motivational interviewing
The value of motivational interviewing is proved. This essentially is an empathic, non-confrontational approach in which the doctor helps the patient identify his or her own reasons for change and strategies for achieving realistic goals. Essential components include sustaining commitment over time, involving the family when possible, acknowledging achievements, and dealing promptly with lapses. A patient's motivation to change his or her way of life fluctuates according to mood and circumstance, and patient and doctor can feel deflated by early setbacks.
Motivational interviewing
The primary care team is ideally suited to provide long term support. Barriers to change need to be identified: some patients will have few barriers; others will have serious impediments that need to be dealt with.
Dependence and detoxification
Some patients will find it hard to cut down or stop drinking because they experience withdrawal symptoms. At first, these may not be recognised for what they are. Patients may describe feeling nervous without a drink or not being able to function effectively until the first drink of the day. Other features in patients who are physically dependent will provide supportive evidence. They vary in severity.
Alcohol withdrawal syndrome
Mild symptoms can be dealt with by rest, relaxation, and reassurance. An explanation that withdrawal symptoms are evidence that the brain has adapted to living in an alcoholic environment and will take time to adjust to one that is alcohol free is helpful. Patients find it reassuring to know that symptoms, however unpleasant, will pass in a few days. This approach is often enough when patients are alcohol free at interview and report drinking < 15 units a day in men and < 10 units a day in women without recent withdrawal symptoms or recent drinking to relieve alcohol withdrawal.
When dependence is more advanced, the discomfort of withdrawal may necessitate medical detoxification. In most cases, this can be done at home, but patients whose symptoms are very severe and who have other prominent physical, psychological, and social factors, need referral for specialist treatment in hospital.
Factors indicating need for specialist or hospital referral
Drug treatment
Benzodiazepines are the drug of choice for managing withdrawal symptoms. Remember that they can induce temporary difficulties in cognition and recall. They are addictive if taken over time, and detoxification with benzodiazepines should not be continued for more than seven days. It is sensible to start with a high daily dose, such as 120 mg chlordiazepoxide or 20 mg diazepam on the first day, and then reduce the dose. After the third day, the dose should have been reduced by at least 25%. Details of the drug regimen should be adjusted to the patient's condition.
This article is adapted from the 4th edition of the ABC of Alcohol, which will be available in February
Other support
Drug treatment is only one part of the treatment for withdrawal. Patients and families should receive a careful explanation and should be advised to stay off work, not drive, rest, and drink plenty of fluids (fruit juice rather than stimulants such as coffee). The need to abstain from all alcohol should be made clear. Ideally, a community nurse or general practitioner should visit daily to monitor progress, review drugs, assess mental state, and vital signs, and, if possible, breathalyse for alcohol. Withdrawal symptoms usually resolve in 4-6 days, after which time patients feel much better and optimistic about the future. They may believe they can now handle alcohol, but it needs to be made clear to patients and carers that on no account should drinking (however little) be resumed. The visiting health professional is well placed to establish a therapeutic alliance for the future and reinforce the need for continued abstinence.
Detoxification regimen
Vitamins
No clear evidence shows that oral vitamins are needed for well nourished people with moderate alcohol dependence. In patients who are undernourished and have a history of frequent relapse and self neglect, however, 200-300 mg thiamine a day over three months or longer will help minimise the risk of damage to the brain and peripheral nervous system. Oral vitamins are absorbed poorly during the early stages of detoxification, so parenteral thiamine may be needed. If the patient is suspected to have or be developing Wernicke's encephalopathy, urgent treatment in hospital with parenteral thiamine is needed.
Detoxification—daily check
Other drugs are rarely necessary. Antacids will help relieve stomach pains. Anticonvulsants are of little value in preventing withdrawal fits, and the management of alcohol dependent people with established epilepsy is best supervised by a specialist clinic. Antidepressants are not indicated at this stage in treatment, and antipsychotics are needed rarely.
Wernicke's encephalopathy
Preventing relapse
The drinker will need to devise strategies to cope with life without recourse to alcohol or with controlled drinking. Some people will find it relatively easy to change this habit; this is often most true of those who identified the problem early and have not developed severe physical, social, and psychological problems.
Triggers to relapse
A drinking diary and a balance sheet of the good and bad consequences of continued drinking, which are often used in the initial assessment, are useful tools throughout follow up, and they can be used to set goals and monitor progress. Patients are encouraged to set their own goals and identify ways of dealing with triggers to relapse. If possible, involve the family in the plan and encourage persistence, even in the face of relapses. Sometimes major barriers to change that are not responding to motivational approaches will be obvious, and more specialist help will be required.
Many problem drinkers risk becoming dependent on benzodiazepines, which have been initiated over a series of failed detoxification episodes.
Pharmacotherapy
Disulfiram
Disulfiram is a well established drug that acts as a deterrent to drinking by blocking the metabolism of alcohol and thus flooding the body with the toxic substance acetaldehyde. This produces flushing, palpitations, nausea, faintness, and in some cases collapse. Very rarely the consequences are serious or even fatal.
Problems most often occur when high doses are taken. An initial dose of 200 mg a day, if tolerated, can be increased after a few days to 400 mg; eventually a supervised dose of 400 mg two or three times a week is usually enough. Disulfiram should not be given to patients with serious active liver disease or cardiovascular disorders, to pregnant women, or patients who are suicidal or cognitively impaired. The action should be explained carefully to patients and their families. Patients should carry explanatory leaflets and a card explaining the actions of the drug.
St Martin, patron saint of alcoholics and alcoholism
The efficacy of disulfiram has been shown only when its use is supervised—for instance, by relatives or by clinic, primary care, or occupational health staff. Disulfiram interferes with the metabolism of other drugs, most notably tricyclic antidepressants, monoamine oxidase inhibitors, heparin, and some anticonvulsants. Drowsiness is noted by some users. Hepatotoxicity is a recognised risk, and regular monitoring of liver function in the early months of treatment is advisable.
Acamprosate
Acamprosate has proved helpful as an adjunct to psychological therapies. It should be started as soon as abstinence is achieved and can be continued during a relapse. If the patient makes good progress, it can be continued for one year. The dose is 666 mg three times daily for patients aged 18-65 years who weigh 60 kg or more. Patients who weigh less than 60 kg should take 666 mg at breakfast, 333 mg at midday, and 333 mg at night. Side effects are rare and are mostly mild gastric upsets.
Naltrexone also improves outcome and reduces the severity of relapse, but it is not yet licensed for regular use in the United Kingdom.
Referral
Referral
Referral to another agency should be timed carefully. Referral should not be too early because the patient may feel rejected; neither should it be too late, when the patient and family have become despondent or further damage has occurred. At the time of referral, a further follow up appointment should be made to find out whether the patient attended and how they got on. The dropout rate at the point of referral is high.
For people with established alcohol dependency, Alcoholics Anonymous is a valuable resource. It is best to make a personal introduction if possible.
Drug treatments should always be accompanied by psychological support and therapy aimed at attaining a longer term change of lifestyle that is essentially drug free
Further reading
? Edwards G, Marshall EJ, Cook CCH. The treatment of drinking problems. Cambridge: Cambridge University Press, 2003
? Freemantle N, Paramjit G, Godfrey C, Long A, Richards C, Sheldon T, et al. Brief interventions and alcohol use: are brief interventions effective in reducing harm associated with alcohol consumption? Effective Health Care 1993;7: 1-13
? Fuller RK, Gordis E. Does disulfiram have a role in alcoholism treatment today? Addiction 2004;99: 21-4
? Garbutt J, West S, Carey T, Lohr E, Crews F. Pharmacological treatment of alcohol dependence: a review of the evidence. JAMA 1999;281: 1318-25
? Miller W, Wilbourne P. Mesa grande: a methodological analysis of treatments for alcohol use disorders. Addiction 2002;97: 265-77
? Slattery J, Chick J, Cochrane M, Craig J, Godfrey C, Kohli H, et al. Prevention of relapse in alcohol dependence. NHS Scotland: Health Technology Board for Scotland, 2002
Competing interests: None declared.
Bruce Ritson is a former consultant psychiatrist, Royal Edinburgh Hospital, Edinburgh EH10 5HD (drbruceritson@zoom.co.uk)
The ABC of Alcohol is edited by Alex Paton, retired consultant physician, Oxfordshire (PatonAlex@aol.com) and Robin Touquet, consultant in accident and emergency medicine, St Mary's Hospital, London (R.Touquet@imperial.ac.uk).
The photograph of people drinking is by Martin Parr/Magnum Photos. The picture of St Martin is with permission of the Bridgeman Art Library.(Bruce Ritson)