eMJA: Sacks & Keks, Alcohol and drug dependence: diagnosis and management

Info Centre Home | Contents | Search | eMJA Home

14 Alcohol and drug dependence: diagnosis and management

Tobie L Sacks and Nicholas A Keks

With empathy and positive management, many drug dependent people can be liberated from their addictions.

Short course--> PDF format	Synopsis - Introduction - Detection, diagnosis and assessment - History - Examination - Investigations - Early interventions and treatment - Detoxification - Maintenance and relapse prevention - References - Suggested further reading - Authors' details - Box 1: Drugs of dependence and misuse - Box 2: CAGE questionnaire - Box 3: A model of change in substance-use disorders - Box 4: Withdrawal syndromes - Box 5: Benzodiazepines in equivalent doses of diazepam - Box 6: Methadone - indications for use - Box 7: Principles of management of substance-abuse disorders - Case history: Complex drug dependence - Short course - Contents list -
Synopsis
	An empathetic and non-judgemental attitude to the patient is required when managing drug dependence problems. Careful assessment to establish the nature and extent of drug use must precede any attempts at management (more than one consultation is likely to be necessary). The active cooperation of the patient in any management plan is essential, as the patient's readiness for change will be a powerful influence on the success of any intervention. Goals for stopping or reducing drug use must be agreed with the patient and must be attainable. Abstinence from drugs will not be every patient's goal; harm reduction (through education to avoid collateral risks or efforts to cut down on drug consumption) is a worthwhile objective. Detoxification is only part of the process. Many lifestyle adjustments are required to maintain a drug-free existence, and these changes may require social support and/or psychological therapies. Relapse is common but can be used as a learning experience. Patients who relapse into drug use should be encouraged to try again.
Introduction
	Alcohol and other drug-related disorders are major causes of morbidity and mortality, accounting for up to 30% of hospital admissions in Australia and 20% of presentations in primary health care settings.¹ About one in five deaths among all age groups in Australia are drug related. In 1990, of the estimated 25 500 deaths attributed to drug use, 71% were due to tobacco, 26% to alcohol, 2% to opiates and 1% to other drugs, including over-the-counter medications.¹ While tobacco accounts for 75% of drug-related deaths in people aged 35 years and older, in the younger 15 to 34 years age group alcohol is responsible for about 65% and opiates for about 23% of drug-caused deaths.¹ In the UK, alcohol consumption is associated with 80% of suicides, 50% of murders, 80% of deaths from fire and 30% of fatal road traffic accidents.²
Detection, diagnosis and assessment
Box 1: Drugs of dependence and misuse Box 2: CAGE questionnaire	Drugs of dependence are listed in Box 1. Patients with drug or alcohol problems are frequently identified when they present with symptoms that may be drug related, or at a well person's check or other screening program, but many will refer themselves because they, their relatives or their employers have become concerned about their drinking or drug use.³ Consider drug abuse or dependence when a patient: Presents with social problems, such as marital or sexual problems (including domestic violence), difficulties at work, legal or financial problems Presents with psychiatric problems, such as irritability or rage states, anxiety, depression, hallucinations, insomnia, repeated accidents or trauma (including repeated episodes of deliberate self-harm), or a decline in usual standards of social concern and personal care Simply requests anxiolytic, hypnotic, antidepressant or analgesic medication, or a medical certificate Has a history of frequent consultations with several different doctors ("doctor-shopping"). The CAGE questionnaire (Box 2), although limited to the detection of alcohol dependence, is a quick and fairly reliable method of determining the likelihood of this problem. Whenever possible, provisional diagnosis of a substance-abuse problem should lead to a follow-up appointment in which further information can be elicited.
History	A complete personal history, including family history, is required. History taking should not focus on drug issues alone, but in the course of exploring their presenting complaints patients should be asked about their consumption of prescribed medications, alcohol and other drugs. Information should also be elicited about the pattern of alcohol and drug use, the amount used or consumed over the past week, whether they have previously tried to reduce or modify their intake, why they did so and what was the outcome. Questions about the onset of drug use and their reasons for using the drug can provide clues about environmental precipitants, such as unpleasant life events or chronic feelings of emptiness or boredom, and can point to unresolved psychological conflicts. Patients' attitudes to their own drug use, including their responses to the comments or concerns of other people about their drug use, should also be elicited. Individuals at risk include those with a family history of alcohol or other drug problems and those with a personal history of childhood abuse, repeated acts of violence or crime, or increasing alienation from family and the community. Questions about patients' social support networks, particularly the existence or the recent development of rewarding or sustaining relationships or involvement with self-help groups such as Alcoholics Anonymous or Narcotics Anonymous, allow the clinician to determine the most appropriate intervention and will provide information about the prognosis.
Examination	Physical examination can reveal objective evidence of self-administration (e.g., needle-tracks or inflamed, hyperaesthetic nasal mucosa), intoxication (e.g., disinhibition, ataxia, sedation, pupillary constriction or conjunctival injection), withdrawal (e.g., tremor, sweating, piloerection or pupillary dilatation) or the sequelae of prolonged drug administration (e.g., hepatitis, arrhythmia, cardiomyopathy, cellulitis, thrombophlebitis). The patient's cognitive functioning, mental status, and readiness for change should also be assessed.
Investigations	Investigations should include a full blood count, liver function tests, screening for HIV and viral hepatitis antigens, urine drug screens and a blood alcohol level (if there is any indication of current alcohol ingestion). About 75% of people with both raised mean corpuscular volumes and gamma-glutamyltransferase levels are likely to have an alcohol problem.
Early interventions and treatment
Box 3: A model of change in substance-use disorders	Doctors can make a significant contribution to harm reduction, prevention and treatment of substance abuse disorders, but many dislike dealing with alcohol or drug dependent patients.² Research into doctors' attitudes towards substance abuse disorders has shown that lack of awareness about effective interventions, negative perceptions of their role in managing these problems and lack of confidence in their skills or knowledge to intervene appropriately significantly affect doctors' management of patients presenting with alcohol or drug problems.⁴ An empathic, educative approach that summarises the facts elicited in the history and physical examination and encourages patients to link their presenting physical and psychosocial problems and the biochemical findings to their drug use will, in most cases, result in an acceptance of the diagnosis.⁵ Motivation to change is reinforced by helping patients weigh up the costs and benefits of their continued drug use and by stressing the benefits of a drug-free lifestyle. Actual change requires the development of a clear, mutually acceptable treatment plan that structures specific interventions to meet the needs of the individual. This is facilitated by establishing a supportive, non-judgmental relationship that encourages active participation. "Motivational interviewing" -- a commonly used early intervention, based on Prochaska and DiClimente's model of change⁶ (Box 3): Provides the pre-contemplative patient with information on drug effects, consequences and safer using techniques Encourages the patient to monitor his or her drug use (e.g., using a drink or drug-use diary) to recognise patterns and the links with other aspects of their lives and to identify "high risk" situations Uses strategies such as exploring the (now contemplative) patient's thoughts, feelings and concerns about his or her substance use to help overcome ambivalence about change (i.e., to progress to the action phase). The therapist selectively reinforces positive self-motivational statements made by patients and helps them to set mutually acceptable and realistic goals to modify their drug use (e.g., having drug-free or alcohol-free days, reducing the drug dose used, not mixing or combining drugs, or changing the method of use). While complete cessation of drug use (abstinence) should be encouraged, a program of "controlled" drug use is often the patient's preferred option. Appropriate (and attainable) goals, in terms of the quantity and frequency of drug use and, most importantly, a "cut-off" (maximum) level of consumption, should then be negotiated with the patient. The situations in which patients are likely to use drugs and the factors that will make it difficult to change their pattern of use can be identified both from their past attempts and from lapses into uncontrolled use during treatment. Positive reinforcement in the form of praise for goals achieved should be provided regularly, especially when there has been a setback or lapse. If such lapses are frequent and the "cut-off" level is exceeded, then complete cessation (i.e., detoxification) should be strongly recommended.
Detoxification Box 4: Withdrawal syndromes Box 5: Benzodiazepines in equivalent doses of diazepam Box 6: Methadone - indications for use Box 7: Principles of management of substance-abuse disorders	The immediate challenge in detoxification is controlling the unpleasant withdrawal symptoms (Box 4). Nicotine: Nicotine is probably the most addictive substance known and most patients will have made numerous unsuccessful attempts to stop smoking. They should be assisted to develop a specific plan to stop smoking. Behavioural modification strategies that anticipate craving and assist in coping with withdrawal include: Delaying having a cigarette for increasing periods of time Self-distraction when craving emerges Documenting whenever a cigarette is smoked as well as the cues and situations that triggered smoking Avoiding these high risk cues and situations.¹ Nicotine replacement therapy with nicotine gum or transdermal nicotine patches is an effective initial strategy that allows patients to modify their responses to the cues that would usually trigger smoking behaviour.⁷ Alcohol: Effective alcohol detoxification can be performed in the home and without medication if the patient is in good physical condition and has previously experienced uncomplicated, mild to moderate alcohol withdrawal symptoms, if supportive relatives or friends will be present, if the patient will not have any access to alcohol, and if there is no history of suicidal ideation or attempts.² A detailed explanation of the process, including a description of symptoms and guidelines on how to deal with them, should be given to patients and their carers.^1,8 A long-acting benzodiazepine, usually diazepam, is the treatment of choice for the prevention and treatment of alcohol withdrawal symptoms.⁹ A loading dose sufficient to relieve withdrawal symptoms (5-20 mg diazepam every 4-8 hours, adjusted depending on symptom severity) is administered over the first 48 hours. Over the next five to seven days the dose of benzodiazepine is tapered to zero. Patients should receive thiamine supplements (100 mg by intramuscular injection on the first day, then 100 mg three times a day orally for two weeks). The patient's orientation, mental status and fluid state should be regularly assessed. Benzodiazepines: Detoxification from benzodiazepines and other sedative-hypnotic drugs is usually performed on an outpatient basis over a period of 6-15 weeks. Having determined the usual daily dose of the abused drug, an equivalent dose of a long-acting substitute, usually diazepam, can be calculated and started (Box 5). After the patient has been stabilised on this dosage (i.e., after 1-2 weeks), the dose should be reduced by 1-2.5 mg of diazepam per week. Regular review, support and encouragement should be provided throughout, but especially towards the end of the program.¹⁰ Opiates: While withdrawal from opiates is generally less severe than withdrawal from alcohol or benzodiazepines, outpatient management of opioid detoxification is less successful than inpatient treatment.⁴ Withdrawal symptoms can be ameliorated with clonidine (15-300 mg every six hours for 3-4 days) and diazepam (10-15 mg every six hours for 3-4 days). The doses should be reviewed daily and then gradually tapered to zero over the next 7-10 days.¹ Alternatively, propranolol and diphenoxylate can be used to relieve withdrawal symptoms.¹¹ While tapering regimens of morphine, heroin, buprenorphine (a partial opioid agonist) and LAAM (L-alpha-acetylmethadol, a very long-acting agonist) have been successfully trialled, short-term substitution therapy (using methadone) is the most commonly used method of opioid detoxification (Box 6). Methadone detoxification can only be offered by specially trained and licensed practitioners. Having established that the patient is physically dependent on opiates, the practitioner titrates the dose of methadone to a level that prevents withdrawal symptoms and "blocks" the euphoric effects of illicit opiates. After a 6-12-month stabilisation period, during which the patient is encouraged to work through problems arising from the former lifestyle, the dose of methadone is gradually reduced over one or two years. Most programs require patients to collect their supplies of methadone daily. Urine tests to detect continuing use of other drugs are required by some programs on either a regular or intermittent basis.
Maintenance and relapse prevention
Case history: Complex drug dependence	The post-detoxification phase of treatment is difficult. Patients are often left without their usual strategy for coping with unpleasant moods and situations. New problems may emerge and older ones, previously suppressed with drugs, have to be faced without the drug or with a considerably reduced intake. The patient may feel physically healthier and may begin to doubt the validity of the initial diagnosis and be tempted to try using the drug again. Clinicians often fail to realise that the patient needs to work through the losses sustained because of their former lifestyle choices. This process is akin to grieving and should be dealt with in a similar manner. Patients will often want to talk about their experiences to understand why they continued to use the drug in spite of an awareness of the likely consequences. Strategies for coping without drugs, including involvement with self-help groups such as Alcoholics Anonymous, Narcotics Anonymous and Smokers Anonymous (which include a form of public grieving in their activities), should be discussed with the patient. Sensitising agents, such as disulfiram for alcohol and naltrexone (a long-acting opioid antagonist) for opioids, are only acceptable to patients who consciously want to maintain drug-free status but need something to protect them against impulsive use and relapse. Tiapride, a substituted benzamine, has been reported to be effective in promoting abstinence following detoxification by patients with chronic alcohol dependence.¹² These agents are more effective in supportive settings that emphasise abstinence and that ensure that the medication is taken. Finally, having successfully assisted the patient to stop using drugs or alcohol, it is important to remember that resolution of the drug-use problem does not automatically improve personal and social function. Problems here have often been incorrectly ascribed to the drug-oriented lifestyle but have, in fact, preceded its onset. Relapse is common and, unfortunately, is often perceived as a sign of failure or lack of motivation by both the patient and the clinician. Clinicians often feel that any mention of the possibility of relapse may subtly communicate an expectation of failure. Relapse thus becomes an issue only when it occurs, and subsequent analysis often takes place in an atmosphere of mutual disappointment and failure. The patient's sense of failure and shame can be mitigated by anticipating the possibility of relapse and by strongly encouraging him or her to maintain contact even if a relapse occurs. A relapse can be seen as a learning opportunity, in which precipitating factors can be identified and alternative strategies developed to deal with them.
References
	Goldman L. Handbook on alcohol and other drug problems for medical practitioners. Canberra: Department of Human Services and Health, 1991. Ashworth M, Gerada C. Addiction and dependence, II: Alcohol. BMJ 1997; 315: 358-360. Dunbar J. Alcohol problems. In: Pullen IM, Wilkinson G, Wright A, Gray DP, editors. Psychiatry and general practice today. London: The Royal College of Psychiatrists and The Royal College of General Practitioners, 1994; 135-152. Roche AM, Parle MD, Stubbs JM, et al. Management and treatment efficacy of drug and alcohol problems: What do doctors believe? Addiction 1995; 90: 1357-1367. Mattick RP, Jarvis T. A summary of recommendations for the management of alcohol problems: the quality assurance in the treatment of drug dependence project. Drug Alcohol Rev 1994; 13: 167-177. Prochaska JO, DiClemente CC. Towards a comprehensive model of change. In: Miller W, Heather N, editors. Treating addictive behaviours: process of change. New York. Plenum, 1986; 3-27. Cornish JW, McNicholas LF, O'Brien CP. Treatment of substance-related disorders. In: Schatzberg AF, Nemeroff CB, editors. Textbook of psychopharmacology. Washington: American Psychiatric Press, 1995: 707-724. Heather N, Richmond R. A guide to healthier drinking. A self-help manual. Sydney: National Drugs and Alcohol Research Centre, 1989. Nutt D, Adinoff B, Linnoila M. Benzodiazepines in the treatment of alcoholism. In: Galanter M, editor. Recent developments in alcoholism treatment research. New York, Plenum, 1989; 283-313. Brayley J, Bradshaw G, Pols RG. Guidelines for the prevention and management of benzodiazepine dependence. Monograph Series No 3. Canberra: National Health and Medical Research Council, 1991. Ashworth M, Gerada C. Addiction and dependence, I: Illicit drugs. BMJ 1997; 315: 297-300. Shaw GK, Waller S, Majumdar SK, et al. Tiapride in the prevention of relapse in recently detoxified alcoholics. Br J Psychiatry 1994; 165: 515-523.
Suggested further reading
	Jarvis TJ, Tebbutt J, Mattnick JP. Treatment approaches for alcohol and drug dependence -- an introductory guide. Chichester: Wiley, 1995. Burrows C. Clued up too -- helping young people with drug issues. Melbourne: Australian Drug Foundation, 1994. Pullen IM, Wilkinson G, Wright A, Gray DP, editors. Psychiatry and general practice today. London: The Royal College of Psychiatrists and The Royal College of General Practitioners, 1994. Pols RG, Hawks DV. Is there a safe level of daily alcohol consumption for men and women? Canberra: National Health and Medical Research Council, 1992.
Authors' details
	The Alfred Healthcare Group, Eastern Healthcare Network, Melbourne, VIC. Tobie L Sacks, PhD, FRANZCP, Director of Community Psychiatry. Monash University, Melbourne, VIC. Nicholas A Keks, MPM, PhD, FRANZCP, Professor, Director of Hospital and Community Psychiatry. Correspondence: Dr T L Sacks, The Alfred Healthcare Group, Eastern Healthcare Network, Prahran, VIC 3181. On to Managing somatoform disorders . . . To Contents list Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> © 1998 Medical Journal of Australia.