Managing the Member with Substance Use: (Alcohol) November 15, Presenter: Steve Edfors, LCPC

Transcription

1 Managing the Member with Substance Use: (Alcohol) November 15, 2018 Presenter: Steve Edfors, LCPC University of Illinois at Chicago College of Nursing 1

2 Learning Objectives Upon completion of this learning module, learners will be better able to: Define the concept of Alcohol Use Disorder (AUD) Discuss the potential physiological and emotional affects of alcohol Recognize the affects of alcohol on men and woman Identify the signs and symptoms of alcohol withdrawal Discuss the various treatment modalities available

3 Quotes A common Alcoholics Anonymous (AA) saying is There is no problem that alcohol cannot make worse. Alcohol is a very patient drug. It will wait for the alcoholic to pick it up one more time. Mercedes McCambridge

4 Why is this important? According SAMHSA s National Survey on Drug Use and Health (NSDUH) 2014 survey, more than half of the adult (older than 12) U.S. population drank alcohol in the past 30 days According to the Centers for Disease Control and Prevention (CDC), alcohol use causes 88,000 deaths a year. Many Americans begin drinking at an early age

5 Change in Diagnosis Terminology DSM IV described two distinct disorders, alcohol abuse and alcohol dependence, with specific criteria for each DSM 5 integrates the two DSM IV disorders, alcohol abuse and alcohol dependence, into a single disorder called alcohol use disorder (AUD) with mild, moderate, and severe sub-classifications

6 The Eleven Symptoms of Alcohol Use Disorder 1. Alcohol is often taken in larger amounts or over a longer period than was intended. 2. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use. 3. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects. 4. Craving, or a strong desire or urge to use alcohol. 5. Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home. 6. Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol

7 The Eleven Symptoms of Alcohol Use Disorder 7. Important social, occupational, or recreational activities are given up or reduced because of alcohol use 8. Recurrent alcohol use in situations in which it is physically hazardous 9.Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol 10.Tolerance 11.Withdrawal

8 The Eleven Symptoms of Alcohol Use Disorder The presence of at least 2 of these symptoms indicates an alcohol use disorder (AUD). The severity of an AUD is graded mild, moderate, or severe: Mild: The presence of 2 to 3 symptoms Moderate: The presence of 4 to 5 symptoms Severe: The presence of 6 or more symptoms

9 What is a Standard Drink? A standard drink is equal to 14.0 grams (0.6 ounces) of pure alcohol. Generally, this amount of pure alcohol is found in: 12-ounces of beer (5% alcohol content) 8-ounces of malt liquor (7% alcohol content) 5-ounces of wine (12% alcohol content) 1.5-ounces or a shot of 80-proof (40% alcohol content) distilled spirits or liquor (e.g., gin, rum, vodka, whiskey)

10 Drinking Levels Defined Moderate alcohol consumption: Moderate drinking is up to 1 drink per day for women and up to 2 drinks per day for men. Binge Drinking: NIAAA defines binge drinking as a pattern of drinking that brings blood alcohol concentration (BAC) levels to 0.08 g/dl. This typically occurs after 4 drinks for women and 5 drinks for men in about 2 hours. The Substance Abuse and Mental Health Services Administration (SAMHSA), which conducts the annual National Survey on Drug Use and Health (NSDUH), defines binge drinking as 5 or more alcoholic drinks for males or 4 or more alcoholic drinks for females on the same occasion (i.e., at the same time or within a couple of hours of each other) on at least 1 day in the past month. Heavy Alcohol Use: SAMHSA defines heavy alcohol use as binge drinking on 5 or more days in the past month.

11 WOMEN: Low-risk drinking is defined as no more than 3 drinks on any single day and no more than 7 drinks per week NIAAA Guideline for Low-Risk Alcohol Use MEN: Low-risk drinking is defined as no more than 4 drinks on any single day and no more than 14 drinks per week. NIAAA research shows that only about 2 in 100 people who drink within these limits have AUD Too much + too often = too risky

12 Plan to drive a vehicle or operate machinery Certain people should avoid alcohol completely, including those who: Take medications that interact with alcohol Have a medical condition that alcohol can aggravate Are pregnant or trying to become pregnant Underage

13 Models of Alcoholism Medical Model Behavior Modification Model Psychological Model Social Model Alcoholic Anonymous Model Multivariant Model

14 Progressive Stage Theory Current Theories of Alcoholism Interpersonal Approach AA Approach

15 Intoxication (getting drunk) Alcohol intoxication can be harmful for a variety of reasons, including 1. Impaired brain function resulting in poor judgment, reduced reaction time, loss of balance and motor skills, or slurred speech 2. Dilation of blood vessels causing a feeling of warmth but resulting in rapid loss of body heat 3. Increased risk of certain cancers, stroke, and liver diseases (e.g., cirrhosis), particularly when excessive amounts of alcohol are consumed over extended periods of time 4. Damage to a developing fetus if consumed by pregnant women 5. Increased risk of motor-vehicle traffic crashes, violence, and other injuries 6. Coma and death can occur if alcohol is consumed rapidly and in large amounts

16 Alcohol Effects Individual characteristics that determine how alcohol affects its user Age Gender Race or ethnicity Physical condition (weight, fitness level) Amount of food consumed prior to alcohol ingestion How quickly alcohol is ingested Use of drugs or prescription medications Family history of alcohol related issues

17 Alcohol Intake Low dose results in depression of inhibitory centers Results in out of character behaviors such as dancing with a lamp shade on the head or blurting out long held confidences High dose results in inhibition of excitatory centers Results in effects ranging from impairment of rational thinking all the way to absence of motor coordination

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19 Chronic Alcohol Use Physiological effects Gastrointestinal: liver cirrhosis, pancreatitis, gastritis, peptic ulcer, cancer, enlarged or shrunken liver or shrunken spleen Cardiovascular: hypertension, cardiomegaly, atrial fib, Spider angiomata Neurological: ataxia, Wernicke s encephalopathy, Korsakoff psychosis, dementia, amnesia, hepatic ancephalopathy Immunological: suppression of immune response Endocrine: males increased estrogen and decrease progesterone leading to impotence, testicular atrophy, and gynecomastia Obstetrics: fetal alcohol syndrome Psychiatric: depression and anxiety disorders

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23 Other effects Unintentional injuries, such as motor-vehicle traffic crashes, falls, drowning, burns and firearm injuries Violence, such as child maltreatment, homicide, and suicide. Excessive alcohol consumption increases aggression and, as a result, can increase the risk of physically assaulting another person Harm to a developing fetus if a woman drinks while pregnant, such as fetal alcohol spectrum Sudden infant death syndrome (SIDS) Alcohol abuse or dependence

24 Options for reducing alcohol-related risks include: How to reduce risk Staying within low-risk drinking limits. If you need to cut down, see Tips to try Taking steps to be safe when you drink Quitting drinking altogether

25 Men and Alcohol Approximately 58% of adult men report drinking alcohol in the last 30 days Approximately 23% of adult men report binge drinking times a month, averaging 8 drinks per binge Men are almost two times more likely to binge drink than women Most (90%) people who binge drink are not alcoholics or alcohol dependent About 4.5% of men and 2.5% of women met the diagnostic criteria for alcohol dependence in the past year

26 Men and Alcohol Injuries and deaths as a result of excessive alcohol use Reproductive Health and Sexual Function Cancer

27 Women and Alcohol Approximately 46% of adult women report drinking alcohol in the last 30 days Approximately 12% of adult women report binge drinking 3 times a month, averaging 5 drinks per binge Most (90%) people who binge drink are not alcoholics or alcohol dependent About 2.5% of women and 4.5% of men met the diagnostic criteria for alcohol dependence in the past year

28 Women and Alcohol Reproductive Health Outcomes Pregnancy Outcomes Other Health Concerns

29 Alcohol and Mental Illness Alcohol dependence co-occurs with mental illness more often than most clinicians realize: >20% of those with mental illness also suffer from alcohol abuse or dependence Alcohol use disorders can cause or exacerbate a wide variety of Psychiatric syndromes, from schizophrenia to the anxiety disorders Alcohol dependence, abuse, or misuse can cause or exacerbate Cluster B personality disorders, and alcoholism itself can be mistakenly diagnosed as a personality disorder Treatment of alcohol dependence and a cooccurring mental illness necessitates a coordinated plan which addresses both problems

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31 Alcohol and Mental Illness Depression Anxiety Bi-Polar Disorder Schizophrenia Personality Disorders

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33 Alcohol Withdrawal Nausea and vomiting Diaphoresis Agitation and anxiety Headache Tremor Seizures Visual and auditory hallucinations: Many patients who are not disoriented, and who do not have delirium tremens, have hallucinations. Delirium tremens (DT) begins 3-5 days after the last drink. DT is characterized by disorientation, fever, rapid heart rate, high blood pressure, and visual hallucinations. o DT is a medical emergency and should be treated on an inpatient basis.

34 Fallacy Controlling drinking is all a matter of will power. If they made up their minds to do it, alcoholics could drink just like everyone else

35 Treatment Integrated Individual/Group Therapy 12 Step Medications

36 The CAGE questionnaire is the most well known Sensitivity is about 75%. It identifies 75% of people who have problems with alcohol Screening Administering the CAGE Questionnaire: Complete the survey face to face Complete prior to asking questions about type, frequency and quantity of alcohol ingested

37 CAGE Questionnaire The following 4 questions make up the CAGE questionnaire: Have you ever felt the need to cut down on your drinking? Have people annoyed you by criticizing your drinking? Have you ever 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? Patients who answer yes to 2 questions are 7 times more likely to be alcohol dependent than the general population. Those who answer no to all 4 questions are one-seventh as likely to have alcoholism as the general population. Thompson, W. et al.,. Alcoholism. Updated: Dec 2, 2010

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39 AUDIT The AUDIT (alcohol use disorders identification test) is the best test for screening because it detects hazardous drinking and alcohol abuse. It is a 10 question test It can be given with paper and pencil Thompson, W. et al. Alcoholism. Updated: Dec 2, 2010

40 Addiction Severity Index Covered in September online Webinar Recommends treatment according to ASAM criteria

41 Additional Questions for Assessment Have you ever had a drinking problem? When was your last drink? (Less than 24 h is a red flag.) Do you use alcohol to relieve pain, anxiety, or insomnia? Have you ever been arrested for drinking, such as driving under the influence? Have you ever lost friends or girlfriends/boyfriends because of your drinking? Have you ever been to an Alcoholics Anonymous (AA) meeting? The following are additional questions specific to older persons: Did your drinking increase after someone close to you died? Does alcohol make you sleepy so that you often fall asleep in your chair? Thompson, W., Lande, G. R., & Kalapatapu, R. K. Alcoholism. Updated: Dec 2, 2010

42 Medications Medication used to treat alcohol addiction help reduce drinking, avoid relapse and maintain abstinence Oral medications: naltrexone, acamprosate, and disulfiram) Injectable medication: extendedrelease naltrexone Topiramate has been shown to be effective but does not have the FDA indication for treatment Folate deficiency is usually present and the person should take supplemental folate National Institute on Alcohol Abuse and Alcoholism NIH Publication

43 Self-Management Encourage attendance at AA meetings Encourage identification of a sponsor Have participant write out list of names and numbers he/she can call if difficult times Encourage identification of high stress situations that may lead them to drinking and ways of coping Encourage exercise and other leisure time activities Assist or refer for assistance with development of new coping strategies Encourage participation of family or significant others if possible

44 Getting Help Consult your personal health care provider if you feel you or someone you know has a drinking problem Other resources include the National Drug and Alcohol Treatment Referral Routing Service available at HELP This service can provide you with information about treatment programs in your local community and allow you to speak with someone about alcohol problems

45 Urge to Drink When urge to drink occurs the person can: Use self distraction do some other activity they enjoy Try to think of something else Avoid activities that remind them of drinking Use social support: call support persons that were previously identified

46 Relapse If relapse occurs institute a treatment plan. Determine what the participant thinks is appropriate treatment Reinforce the participant's decision to seek help Emphasize that complete abstinence is the only solution Reframe the relapse as a learning opportunity Provide support and empathy Have the patient come up with ways to avoid the triggering event or find alternative ways to deal with it Rehearse what to do in high-risk situations, including making use of the patient's social support system Thompson, W., Lande, G. R., & Kalapatapu, R. K. Alcoholism. Updated: Dec 2, 2010

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48 Different Types of Treatment

49 What Do I Do? 1. If there is imminent danger (the person is not responding, having difficulty talking or breathing, not thinking clearly, etc.), stay with the member and call emergency services 2. If the person has an ongoing problem that is not resolving or getting worse, assist the member in seeking more help: A. Use your team B. Call providers to communicate symptoms C. Assist in getting further evaluation D. Follow-up

50 Assessment Before Transition What is the member s past experience with substance use? What is current frequency and quantity of use? If member reports sobriety, how long have they been sober and how was sobriety achieved? Are there co-occurring mental health conditions present? What support systems does the member have in place? What is the member s motivation to obtain / maintain health?

51 Assessment After Transition Assess the member for changes in appearance, hygiene, alertness, and/or personality Check prescription medications to determine any misuse Look in the bathroom, refrigerator, and cabinets for hidden signs of substance use Be aware of unknown individuals and their impact on the member s substance use Check on the member s finances. Have they changed? Do they have all the possessions they had at the last visit? Are they meeting their basic needs?

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53 Chicago Area 19 Alcoholics Anonymous Use your zip code to find a local meeting! Go to: Resources

54 Resources Substance Abuse and Mental Health Service Administration: National Institute on Alcohol Abuse and Alcoholism: National Counsel on Alcohol & Drug Dependence:

55 Resources Drug Policy Alliance (DPA) National Institute on Drug Abuse (NIDA), Rational Recovery, U.S. Drug Enforcement Agency (DEA),

56 References Cohagan, A., Worthington, R., Amy Cohagan, & Krause, R. DO. Alcohol and Substance Abuse Evaluation. Updated: Oct 21, Flores, Philip, PhD. Group Psychotherapy with Addicted Populations, The Haworth Press, 1997 National Institutes of Health National Institute on Alcohol Abuse and Alcoholism NIH Publication October 2008 Update Materials/Documents/PrescribingMeds.pdf

57 References Thompson, W., Lande, G. R., & Kalapatapu, R. K. Alcoholism. Updated: Dec 2, overview The Alcohol Use Disorders Identification Test (AUDIT)Guidelines for Use in Primary Care, Thomas F. Babor, John C. Higgins-Biddle, John B. Saunders, Maristela G. Monteiro

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59 . Thank you all for being here and for your commitment to improving the health and well-being of your client members