Substance Misuse Nurse service Belfast Trust

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1 Substance Misuse Nurse service Belfast Trust

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3 Alcohol is the most widely available socially acceptable drug in Northern Ireland It can be an addictive substance It is a depressant- slows down the central nervous system For some a pleasurable substance People drink at different levels

4 Social drinker Hazardous Harmful Binge Dependant

5 Addiction A compulsive physiological and psychological need for a habit forming substance Body adapts to the substance being used and gradually requires increased amounts to reproduce the effects originally produced by smaller doses DSM-IV Criteria for substance abuse and substance dependence

6 When you can stop you don t want to and when you want to stop you cant

7 High mortality rate Alcohol interferes with platelet production Risk associated with falls especially head injury Deranged electrolytes Risk of withdrawals and delirium tremens Risk of seizure activity Liver disease.

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9 Alcohol-related harm in Northern Ireland Estimated to cost society up to 900 million every year (10% of the entire block grant the NI Executive receives from Westminster). HSC sector alone up to 250 million every year. alcohol abuse costs every person in Northern Ireland 500 a year. annual number of hospital admissions due to alcohol-related illness rose by 61% between 2000/01 and 2009/10

10 Alcohol Liver Disease: Measuring the Units found that 71% of those who eventually died from alcohol liver disease attended hospital at least once, in the 2-years before their final admission They commented; -Not enough was done about the patient s harmful drinking at the time -There was a failure to screen adequately for harmful use of alcohol -Those identified as having alcohol misuse disorder were not referred for support

11 Consecutive patients attending the ED in RVH and MIH were screened for the presence of an alcohol misuse disorder using the AUDIT-C at the time of triage. Patients who were medically unfit, intoxicated or refused were counted but not screened RVH November 2013 two weeks Mater January 2014 one week

12 49% of attendees at ED across both sites in a time equivalent of 1 week were identified as drinking beyond safe limits 21% (235) were potentially hazardous/dependent drinkers and therefore suitable for referral to SMLN This is likely to be an under estimation many individuals were either medically unsuitable for screening or intoxicated despite best efforts not everyone attending during the study period could be screened It is therefore clear that the extent of the problem is too large to ignore

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14 Q.1. How often do you take a drink containing alcohol? Never (0) Monthly or less (1) 2 to 4 times a month (2) 2 to 3 times a week (3) 4 or more times a week (4) Q.2. How many drinks containing alcohol do you have on a typical day when you are drinking? 1 or 2 (o) 3 or 4 (1) 5 or 6 (2) 7 to 9 (3 ) 10 or more (4) Score Q.3. How often do you have six or more drinks on one occasion? Never (o) Less than monthly (1) Monthly (2) Weekly (3) 4 or more times a week (4) Total score (add numbers for each question)

15 Audit Score under 5 No further intervention Positive reinforcement Audit score 5-7 (lower risk) Brief Advice by staff Audit score of 8 or above Refer to SMLN

16 Male and female 14 units per week 2-3 free alcohol free days per week

17 The old unit guidelines hadn t been reviewed since During their current review the four UK chief medical officers found significant new evidence on the effects of alcohol that was not available at the time when the original guidelines were produced. In particular, there is now much stronger evidence available that the risk of cancers, especially breast CA, increases directly in line with the consumption of alcohol. The idea of counting alcohol units was first introduced in the UK in 1987 to help people keep track of their drinking. Knowing your units should help you to stay in control of your drinking and reduce the risk of harming your health and wellbeing.

18 It is estimated that alcohol is responsible for about 3% of all causes of cancer. Cancers of mouth, larynx, pharynx and oesophagus People who drink 5+ units daily have an increased risk of developing these. Those who smoke and drink have an increased risk. other cancers heavy drinking is associated with cancer of liver and cancers of colon, stomach and rectum. Breast cancer link between alcohol and breast cancer and risk increases by 6% for each additional unit consumed daily

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20 Reasons for patients undergoing detox from alcohol in general hospitals include... Elective admissions for detox at GP s request. Pt self-presents and requests detox in ED? Pt attends ED in moderate/severe withdrawal and with history of w/d problems. Medical conditions that necessitate admission to hospital. Pt admitted for elective surgery or treatment of other conditions. Addictions Services BHSCT

21 History taking should include: Drinking pattern i.e. daily/continuous or episodic/binge drinking (consider accuracy of self reporting, consider collateral info sources) Date and time of last drink Amount of alcohol consumed per day/week. Previous episodes of withdrawal and likelihood of complicated w/d Co-existing medical or psychiatric problems. Other drug use/abuse including prescribed meds Ideally commence detox 6 8 hrs after alcohol cessation and BAC zero or close to zero. Addictions Services BHSCT

22 Chordiazepoxide is drug of choice in B.H.S.C.T. Q.I.D. and P.R.N. doses Reducing dose/review daily Regime varies depending withdrawal symptoms gender,body mass and unit intake Discharge doses.

23 Lorazepam is used with patient with liver impairment. Jaundice, ascites, encephalopathy clinical stigmata of cirrhosis. 1-2mgs daily for 3/7 reduce by 1mg per day Lorazepam 1mg=25mg Chlordiazepoxide. No more than 8mgs po daily or 4mgs i/v

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26 Drinking too much alcohol can lead to three types of liver conditions- Fatty liver Hepatitis Cirrhosis Any, or all of these conditions can occur at the same time in the same person. Some people with advanced liver disease have normal liver function tests.

27 What is dual diagnosis

28 Dual diagnosis is the term used when a person has a mood disorder such as depression or bipolar disorder (also known as manic depression) and a problem with alcohol or drugs. A person who has a dual diagnosis has two separate illnesses, and each illness needs its own treatment plan.

29 a vicious cycle If you drink heavily and regularly you re likely to develop some symptoms of depression. It s that good old brain chemistry at work again. Regular drinking lowers the levels of serotonin in your brain a chemical that helps to regulate your mood. In the U.K research has shown, people who experience anxiety or depression are twice as likely to be heavy or problem drinkers. For some people, the anxiety or depression came first and they ve reached for alcohol to try to relieve it. For others, drinking came first, so it may be a root cause of their anxieties. If you use drink to try and improve your mood or mask your depression, you may be starting a vicious cycle

30 Soon after drinking alcohol, your brain processes slow down and your memory can be impaired. After large quantities of alcohol, the brain can stop recording into the memory store. That s why you can wake up the next day with a blank about what you said or did and even where you were. This shortterm memory failure or black out doesn t mean that brain cells have been damaged, but frequent heavy sessions can damage the brain because of alcohol s effect on brain chemistry and processes. Drinking heavily over a long period of time can also have long-term effects on memory. Even on days when you don't drink any alcohol, recalling what you did yesterday, or even where you have been earlier that day, become difficult.

31 Reasoning, judgement, inhibition and empathy. Movement and coordination. Stagger. Reactions impaired. Eyesight Speech begins to slur. Aggression also affected. Controls automatic functions. Too much alcohol can make this shut down and cause unconsciousness. Hearing suppress ed. Controls vital functions like your heart beat and breathing. When this shuts down, you die!

32 Can result in ARBD Range of conditions characterised by impaired mental function Best seen as a spectrum of disorders, which merge and overlap with each other Wernicke s korsakoff s syndrome to Alcoholrelated Dementia. (Jacque and Stevenson, 2000)

33 Obtain a history from patient family or friends Always C/O I/V Pabrinex (oral is not adequate) Dose should be 2 pairs TID for 5 days or until no further clinical improvement(can give up to 3 pairs) Cognitive screen MDT input plan tailored to patient needs

34 In theory entirely preventable disorder Significant number of those with ARBD recover if managed in an appropriate environment, free of alcohol. Move on accommodation is a major problem, WHY?

35 8 out of 10 patients with Wernickekorsakoff syndrome are only diagnosed at post mortem

36 Voluntary and involuntary services Hostels Rehab

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