What drugs are we using these days_ -

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					Inpatient treatment & care
  of people withdrawing
   from alcohol & other
Dr Enrico Cementon
OCP Inpatient Leadership Forum June 2012
       You’ll also find it at:

NWMH AOD Withdrawal Management
 Guidelines intranet site
             Executive summary
• 41 inpatient deaths, 29 most likely suicide
• 13 after absconding from IPU
  – At least 2 OD opiates
• 2 in ED with dual diagnosis
• Management of co-morbid substance use
  a key theme
  – Opiates implicated in 4 deaths
  – Drug-seeking a motivation for absconding
  – Lack of intervention-planning for AOD
  SUMITT Clinical Review Audit
Start 2001 to end 2004
• 212 patients

                  t ie en he
  – 41 (19%) re-referred during 4-year

                      nt de
                pa ep t
                    -d E

                 id AR
• 4 deaths     io W
             op B E
  – All Dx psychosis & depression
  – 3/4 OD multiple substances including
    heroin; 4th opioid dependence
DD in 15 Recommendations
DD in 15 Recommendations
              Dual Diagnosis

• Co-occurrence of mental health & substance
  use disorder
• Narrowed definition in MH literature of serious
  mental illness & substance use disorder
     Implications of comorbidity

• Poorer prognosis
• Poor Rx compliance        •   Homelessness
• Repeated                  •   Violence
  hospitalisation           •   Imprisonment
• Problems with             •   Early mortality
• Suicide
  e.g. Drake et al (1996)       e.g. McEvoy (2000)
.Time……. …….Time…… …….Time…….. …….Time…… …….Time……..

   Exclusion                                           ‘multi-agency,
                              Routine                    Joint -ISP’
                            SCREENING                 INTEGRATED

                                                                                        NO WRONG
  DDx / comorbidity capability spectrum                                                  Service

                                          Routine               ‘1-stop shop’
      recognition of
                                       INTEGRATED              INTEGRATED
                                       ASSESSMENT               TREATMENT

 1.          2.        3.           4.      5.
                                             SUMITT     6.       7.           8.   9.       10.
                              Gary Croton                       Darren Bate
      What does this “integrated”
            really mean?
• Awareness that co-occurrence is frequent, nor
  by chance
• Always a relationship between disorders è
  affects outcomes
• Recognition that effective responses to people
  with either mental illness or AOD disorders are

                  SAMSA’s Co-occurring Center for Excellence (2007)

Detection of substance use in MHS
• Frequent under-detection
• Suspect when
  –   Frequent DNA’s
  –   Poor Rx adherence
  –   Mental state instability
  –   Social/financial/legal problems   Green et al (2007)
• Obtain collateral information
  – Family, carer, case manager
  – Ix: bloods & UDS/GCMS
           Assessment Process
       Every client


             If Positive      Comprehensive
                              Dual Diagnosis

      If negative
                                               Dual Diagnosis
  Continue mental                              Treatment Plan
 health assessment         SUMITT
  Screen: Clinical Observation
• Observe for signs of:
  – Intoxication
  – Withdrawal
  – Effects of chronic use
  – Signs of recent use

• YES to any of the above triggers full
• If in doubt, proceed to full assessment

Pupil size
and drug use

        (and opioid

      MDMA- Ecstasy
Assessment – Alcohol Use
Recommended Drinking Guidelines
Guideline 1
Reducing the risk of alcohol-related harm over a lifetime.

For healthy men and women, drinking no more than two standard drinks
   on any day reduces the lifetime risk of harm from alcohol-related
   disease or injury

Guideline 2
Reducing the risk of injury on a single occasion of drinking*

For healthy men and women, drinking no more than four standard drinks
   on a single occasion reduces the risk of alcohol-related injury arising
   from the occasion.

* A single occasion of drinking refers to a sequence of drinks taken without
    the blood alcohol concentration reaching zero in between.
Assessment – Alcohol Use
Recommended Drinking Guidelines
Guideline 3
Children and young people under 18 years of age.

-   Parents and carers should be advised that children under 15 years of age
    are at the greatest risk of harm from drinking and that for this age group, not
    drinking alcohol is especially important.
-   For young people aged 15-17 years, the safest option is to delay the
    initiation of drinking for as long as possible.

Guideline 4
Pregnancy and breastfeeding

-   For women who are pregnant or planning a pregnancy, not drinking is the
    safest option.
-   For women who are breastfeeding, not drinking is the safest option.
‘A Standard Drink’
         SUD Diagnoses
• DSM-IV            • ICD-10 (F10-19)
  – Substance Use      – Harmful use
    disorders            (Fx.1)
     • Substance       – Substance
       Abuse             dependence
     • Substance         (Fx.2)
       Dependence      – Substance-
  – Substance-           Induced
    Induced              disorders follow
    disorders            (Fx.3-9)
         Multiple diagnoses
• List all applicable diagnoses
   – both substance use & substance-
• List separately if Dependence diagnoses
  met for different drug classes
• Once criteria for Dependence met, can
  never have diagnosis of Abuse for that
  drug class
• ‘Polysubstance abuse’ does not exist!
 Models of comorbidity treatment

• 1. Integrated

• 2. Sequential

• 3. Parallel
         1. Integrated treatment
• Mental health treatments and substance abuse
  treatments are brought together :
  – same clinicians/support workers, or team of clinicians/support
  – same program
  – to ensure a consistent explanation of illness/problems and a
    coherent prescription for treatment rather than a contradictory
    set of messages from different providers
• Developing evidence base
• Regarded as current best practice
        2. Sequential treatment
• One treatment (either mental health or
  substance abuse) followed by the other
• first deal with one set of problems and then the
• for comorbid anxiety/mood-substance use
• eg. 1° alcoholism è 2 ° depression
           3. Parallel treatment
• concurrent treatment of both the
  psychiatric disorder(s) and substance use
  disorder(s) by two separate agencies,
  – different goals eg. abstinence vs. harm min
  – different methods eg. confrontation vs. client-
    centredness; assertive case management vs.
    personal responsibility
  – exclusion of particular groups of comorbidity
  – disputes over prime clinical responsibility
3. Parallel treatment
.Time……. …….Time…… …….Time…….. …….Time…… …….Time……..

   Exclusion                                       ‘multi-agency,
                              Routine                Joint -ISP’
                            SCREENING             INTEGRATED
                                     But we      want to know

                                      about withdrawal
                                                                                  NO WRONG
                                        management !                                DOOR
  DDx / comorbidity capability spectrum                                            Service

                                          Routine         ‘1-stop shop’
      recognition of
                                       INTEGRATED        INTEGRATED
                                       ASSESSMENT         TREATMENT

 1.          2.        3.           4.      5.      6.     7.           8.   9.       10.
                              Gary Croton                 Darren Bate
Inpatient integrated treatment of
     dual diagnosis patients
• Stabilisation of acute medical
• Detoxification:
  •   ê withdrawal Sx
  •   Prevent serious complications
      •   DT’s, seizures, exacerbation of psychosis, death

• Concurrent psychiatric Rx
        Substance withdrawal
• Substance - specific
• Maladaptive behavioural change
  – physiological & cognitive
• Due to cessation or reduction after
• Heavy & prolonged substance use
• S&S usu. opposite of intoxication
  effects                     DSM-IV-TR (2000)
     Withdrawal symptoms generally start within 6 to 24
     hours of the last drink and peak over 36 to 72 hours.
                                           Severe hypertension

                  ALCOHOL WITHDRAWAL

Seizures (usually occur within the first 48 hours following
cessation of drinking)
 The following are features of OPIOID
          withdrawal except?
• Sweats, yawning, lacrimation &
• Restlessness, irritability, anxiety
• Dilated pupils, gooseflesh
• N&V, diarrhoea, sleep disturbance
• Deep muscle & joint aches & pains
• Hallucinations and seizures
• Duration 5-7 days for heroin
• Clearing of toxins
• Management of the withdrawal
  – Prediction or early recognition crucial
  → Prevention of, or urgent intervention in,
    potential medical/psychiatric emergency
  Acute substance withdrawal in
       psychiatric patients
• Typically unpleasant symptoms
  – Physiological, Psychological, Cognitive
• Exacerbation of underlying or associated
  conditions → confused clinician!
• Potentially serious medical conditions:
  – Dehydration, electrolyte imbalance, cardiovascular
    instability, infection
  – Seizures, delirium
       Goals of detoxification
•   Provide safe withdrawal → patient
•   Provide humane treatment &
    protect patient’s dignity
•   Prepare patient for ongoing
    treatment of drug dependence
        Pharmacological strategies in
          withdrawal management
•       Suppress withdrawal with cross-
        tolerant Rx
    –    Usu. with longer-acting drug
•       Withdrawal reduction by altering
        another neuropharmacological
        process: “Symptomatic management”
•       Maintenance of other psychotropic Rx
  What if the withdrawal does not
           proceed well?
• Much individual variation
• Continuous re-assessment required
• Check withdrawal Rx dosing
  – If inadequate → ↑ dose
  – If adequate → consider other, non-addictive
    Rx e.g. antipsychotic for agitation, anxiety
  – NB. Consider drug interactions & side-
• Consider possibility of acute medical problem
What medication prescribing regime is
Management Alcohol withdrawal
                                    Drink plenty of fluids (e.g. 2
                                    - 3 litres of water or fruit
Avoid caffeine and/or                          juice daily)

        Eat light and healthy
        meals (small meals
        several times a day are
                  better than one                Consider thiamine
                  large meal)                    replacement
Medical Management Alcohol withdrawal

       Doses of diazepam vary widely.
       Some 5-10 mg a day, others, if
       tolerant to benzodiazepines may
       need very high doses (160-200 mg) a
       day. Generally, doses greater than
              40 mg a day require inpatient
Management of opioid withdrawal

 Buprenorphine is the
    most effective
 pharmacotherapy in
 the management of
  opioid withdrawal

                            Dosing is initiated after a
                            patient shows signs of
           Schedule 8       opioid withdrawal.
         medication. No     Dosing too early
         need for permit    precipitates withdrawal
         in hospital, but
           must inform
Plan post-withdrawal management
• Engagement in detoxification
• Evidence of long term benefits &
  reduced relapse rates
  – Pharmacotherapy options
  – Support & counselling
  – Relevant information & resources
• Advise reduced tolerance → risk of OD
• Avoid maintenance benzodiazepines
 Dual diagnosis pharmacotherapy:
         general principles
• Treatment for psychosis generally urgent
• Non-psychotic patients: may use
  longitudinal assessment, stabilise drug
  use first
• If reasonable probability of treatable
  disorder è treat e.g. depression, anxiety
• Medication in SUD treatment is only ever
  an adjunct
• Avoid prn’s esp. benzo’s
     Other issues in PharmacoRx
• Interactions
  – Pharmacokinetic & Pharmacodynamic
  – Risks:
     • OD, sedation, drowsiness, impaired
  – Avoid maintenance benzodiazepines
• Consider Rx specific to D&A field
  – Anticraving Acamprosate, Naltrexone
  – Substitutions Methadone, Buprenorphine
    (Suboxone, Subutex)
  – Disulfiram ‘renaissance’
          Opiate Dependence
• Opioid use, especially heroin, confers particular
  risks for morbidity & mortality
   – Sedation, respiratory depression, OD
   – Especially when combined with other drugs
     e.g. alcohol, benzo’s, antidepressants,
   – Also general risks associated with IVDU e.g.
     local infection, blood-borne virus
• Will require consultation +/- referral to local AOD
  service or DACAS (Ph: 9416 3611)
     Revisit old ideas for our IPUs?

• Breathalysers
• Needle disposal boxes
• Rapid result UDS

• Comorbidity or “dual diagnosis” as the
• Co-occurring, long-term, chronic relapsing
  – Cycles of remission & relapse as part of recovery !
  – Cycles not necessarily synchronized
  → Implications for interventions’ matching
• Legacy of separate MH & AOD systems
  – Barriers to integrated assessment & treatment
              Last messages
• Record all MH & SUD diagnoses
• Integrated treatment
   – Current best practice
   – Consider all presenting MH & substance use
     problems as primary
   – Compatibility of responses to DD
• Withdrawal management or detox is
  only the start of the addiction recovery

So let’s move onto the next step
in the change process to dual
diagnosis capability …

Integrated & treatment !
       Thank you
• Drug & Alcohol Clinical Advisory Service
  (DACAS) Ph: 9416 3611
• Directline Ph: 1800 888 236
• Family drug help Ph: 1300 660 068
• Drug Health Services, Western Health
  (previously DAS West) Ph: 8345 6682
• DPU Ph:1300 364 545
• Medicare Prescription Shopping Program
  Ph:1800 631 181
• Reconnexion Ph: 1300 273 266
• SUMITT Ph: 8387 2202

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