ROLE OF HEALTH CARE PROVIDERS IN THE MANAGEMENT OF ALCOHOL AND DRUG USE RELATED PROBLEMS

Transcription

1 ROLE OF HEALTH CARE PROVIDERS IN THE MANAGEMENT OF ALCOHOL AND DRUG USE RELATED PROBLEMS Dr. Anita Rao? ASK SCREEN Refer HELP T T Ranganathan Clinical Research Foundation TTK Hospital IV Main Road, Indira Nagar, Chennai , India. Phone: / / Fax: ttkhospital@gmail.com, Website: June

2 Alcohol and drug use can impact health, work performance as well as family and social relationships. Yet, unlike other diseases, people may not be able to recognize the problems caused due to hazardous alcohol / drug use. Health care providers can help to: - Identify alcohol and drug use problems in the early stage and assess level of risk - Intervene by providing medical support and advise - Refer patients for specialized addiction treatment services if required. I. EARLY IDENTIFICATION THROUGH ROUTINE SCREENING ASK? As a routine, ask all patients if they drink alcohol or use other drugs without a physician's prescription. Some may report using more than the recommended dosage of prescription drugs (sleep inducing drugs such as diazepam or pain killers such as propoxyphene). Few may use illicit drugs such as heroin (brown sugar) or cannabis (ganja). Explain that even occasional use of small amount of alcohol and drugs can lead to accidents, falls, violence etc. Harmful level of alcohol/ drug use can lead to general deterioration of the body by reducing appetite, altering sleep patterns etc., It can also lead to : - Liver disorders such as fatty liver, alcoholic hepatitis, cirrhosis etc., - Gastro intestinal disorders (gastritis, ulcers, esophageal varices, pancreatitis etc.) - Neurological problems (neuropathy, dementia, etc). - Regular use can also increase the risk of dependence or addiction. - Use of drugs like cannabis can trigger a psychiatric break down. - Sharing of injecting equipments can lead to HIV, hepatitis B or C or other blood borne infections.

3 If no use is reported, we can say, We are happy that you do not use alcohol or other drugs. You have made a smart decision. If use is reported, enquire about the quantity and frequency of use. (Please note: 30 ml of distilled spirit such as brandy/whisky/vodka equals one unit of alcohol and 650 ml of beer can be treated as 2 units of alcohol). If patient uses not more than 3 units of alcohol in a day and not more than 7 units a week, message of caution can be given by saying : As of now you are not drinking heavily but make sure you do not increase the quantity or frequency of use. Remember that even small amounts of alcohol can cause accidents especially while driving or operating machinery. If patient reports occasional use of drugs (illicit drugs or prescription drugs without advice of physician), state : Drug use can quickly develop into addiction. It would be best for you to stop using it If patient uses alcohol more than 3 units a day or more than 7 units a week and / or regular use of drugs with or without associated problems : - With alcohol users administering a screening test such as AUDIT can help. SCREEN - If patient uses other drugs, provide information about health problems associated with that particular drug. - Assess for addiction. If the patient experiences craving to use, finds it difficult to restrict quantity / frequency of use or continues to use alcohol or drugs in spite of negative consequences, addiction may have developed. It is important to assess level of Substance Use Disorder based on criteria listed in DSM 5.

4 WHAT NEEDS TO BE DONE? Patient is NOT substance dependent Explain the consequences of continuing with present pattern of alcohol/drug use. Help patient develop a plan to reduce or stop use (avoid drinking places, handle stress, boredom or other problems without resorting to use of alcohol/drugs, saying No to offer of alcohol/drugs etc). Ask patient to maintain record of alcohol/drugs used and provide guidance based on its record during followup visits. Patient could be substance dependent Explain consequences of continuing with present pattern of alcohol/drug use. Provide medical help to deal with withdrawal symptoms if needed Refer patient for specialized addiction treatment services. Suggest attending AA/NA self help group meetings ( A l c o h o l i c / N a r c o t i c s Anonymous). II. Medical management of withdrawal symptoms : HELP The nature and severity of withdrawal symptoms depends largely on the type and quantity of alcohol/drug used and health condition. Most patients require vitamin supplements while alcohol users often require antacids, liver supplements and large doses of thiamine to prevent onset of Wernicke's disease. Those with history of withdrawal fits need anti-convulsants. Injectable diazepam or lorazepam can be used in case of agitation. As psychiatric comorbidity is common among addicted patients, anti depressants, anti psychotics and mood stabilizers may be required. The most commonly noted withdrawal symptoms and its management are listed below.

5 Type of substance Withdrawal symptoms Medications suggested - Alcohol - Benzodiazepines (diazepam, alprazolam) Cannabis (Ganja, hashish, bhang) Tremors, insomnia, anxiety, seizures, h a l l u c i n a t i o n s, delirium. Insomnia, restlessness, sweating, loss of appetite. D e p r e s s i o n o r psychotic symptoms may become prominent. - Chlordiazepoxide 50 to 200 mg in divided doses depending on severity for 3 to 5 days and tapered off in 7 days. - A n t i - c o n v u l s a n t s i f required. - Delirium can be life threatening and is best managed in a setting equipped to deal with medical emergencies. - S y m p t o m s a r e n o n s p e c i f i c a n d Chlordiazepoxide may be used for 3 to 5 days and tapered later. Opioids (heroin/brown sugar, pentazocine, propoxyphene) B o d y p a i n, r e s t l e s s n e s s, diarrhoea, vomiting, body chills alternating with sweating, watery discharge from eyes and nose. - Clonidine (0.3 to 0.6 mg) for 3 to 5 days and tapered off in 7 days. - Chlordiazepoxide may be used for sleep and stopped in 7 days. III. Medical management of withdrawal symptoms: Refer Providing medical assistance to manage withdrawal symptoms in a safe and comfortable manner (detoxification) alone cannot be considered as treatment for addiction. Addiction is a brain disease and patients require help to give up use of alcohol/drugs completely and make qualitative lifestyle changes to support the decision to remain drug free.

6 Addiction treatment should comprise of four core components and TTK Hospital offers an one month programme that encompasses all of these. a) Medical assistance to handle physical and mental health problems caused by or made worse by substance use and pharmacotherapy (disulfiram, naltrexone etc) to support abstinence. b) Psychological therapy wherein information is provided about addiction and recovery as well as group therapy and counseling sessions to establish abstinence from mood changing substances and improve quality of life. c) Family therapy to assist family members in their own recovery and provide appropriate support to patient. d) Follow-up services to sustain recovery. Addiction is a treatable disease. By presenting facts, expressing optimism about their ability to make changes and providing some help, health care providers can : - Act as prevention agents and dissuade people from using alcohol/drugs - Intervene to reduce harmful use of alcohol/drugs - Carry out referrals for addiction treatment in the early stages increasing the prognosis of recovery. TTRCRF (TTK Hospital) started in 1980 is a premier non profit professionally managed 100 bed addiction treatment centre. It runs a residential one month primary care programme and a two month extended care treatment programme. Community based treatment camps are conducted for the rural poor in Tamil Nadu. TTK is also involved in awareness building, work place prevention, training and publications related to addiction.