Link to 220.127.116.11.3 Alcohol Dependence
This can be classified into primary prevention (i.e. preventing drug and alcohol problems developing in the first place), secondary prevention (of complications in patients with abuse) and tertiary prevention (of further problems in those with established alcohol and drug dependence).
This is concerned with such things as legal restraints, education etc. and a discussion is beyond the scope of this monograph.
In the context of alcohol related disease, secondary prevention refers to the prevention of alcohol related disease by recognising the association between drinking and individual medical conditions, drawing this to the patient's attention, and assisting them to change. This is the area which impacts most on medical practice and where general practitioners can make their greatest contribution in dialogue with individual patients.
There are six steps to follow in intervening with a patient whose medical problems are associated with their use of alcohol:
As with alcohol, this is often the area where doctors can be most effective.
Firstly, do not become an unwilling or inadvertent supplier of narcotics. Heroin dependent patients can become very expert at “scamming” the doctors and it is important to be on the alert. Most doctors are familiar with the presentation late in the day with a dubious story of chronic pain and no documentation and it is obviously good practice never to prescribe narcotics for a patient you don't know unless you are able to check the documentation yourself.
Rather more difficult to deal with are the patients who explain they are on a methadone program but cannot get to the clinic today, and those who say they are heroin addicts, are “hanging out” and will do something desperate if they can't get help.
Dealing with patients in the first category is relatively straight forward. Methadone is long acting and serious withdrawal will not occur from missing one dose. If the patient is in transit, then arrangements will have been made for transfer from one clinic to another. The patient should be told to present to their prescriber as soon as possible.
For patients in the second group, there are a number of options. They can be referred to the nearest drug dependence clinic, or they can be offered a supervised withdrawal using either clonidine or just symptomatic treatment or they can be managed in cooperation with a drug dependence clinic whose advice can be sought by phone.
No matter which of the above alternatives are offered, it is always possible to make a “reasonable offer” of treatment which does not involve using narcotics. Most users will realise that the game is up at that point and take their business elsewhere but some may accept the offer of detoxification and referral to a specialist agency.
In New South Wales there is a Drug and Alcohol Specialist Advisory Service (Phone No: (02) 557 2905) which will provide advice from a specialist in Alcohol and Drug problems 24 hours a day, seven days a week. It is strongly recommended that you use this service when in doubt.
A summary of the management of narcotic withdrawal is provided elsewhere.
Apart from avoiding the prescription of further narcotics, the other important aim of secondary prevention is the prevention of the spread of HIV and Hepatitis B and C. Every time an intravenous drug user is seen they should be reminded of the importance of using clean needles and safe sexual practices. Every surgery should have a list of local needle and syringe exchanges, and intravenous drug users presenting for treatment should have tests for HIV and Hepatitis B & C antibodies performed. These should be repeated in three months if negative, and at three month intervals if the patient continues to use.
A discussion of Hepatitis C is beyond the scope of this monograph, but making the diagnosis early, encouraging the patient into treatment and early referral to a liver clinic for assessment is important if the patient is to have the maximum chance of benefiting from interferon treatment.
Finally, family members, and the patient if HbsAg negative, should be vaccinated against Hepatitis B.
As with alcohol, the most important step in secondary prevention of the complications of amphetamine use is to be aware of the possibility. Therefore, symptoms, signs and ECG abnormalities of ischaemic heart disease in younger people should be an indication to ask tactfully about the use of illegal drugs. Similarly the other medical problems will tend to present in young men who may well be fairly frank about their drug use and who probably never considered that there was a possible risk to them.
Amphetamines used to be taken most commonly by mouth or by “snorting” but over 60% of amphetamine users these days use the drug intravenously. For this reason it is just as important if not more important in amphetamine users than in heroin users to check HIV and Hepatitis antibodies and to emphasise the importance of using clean needles and safe sexual practices.
The benzodiazepines are virtually free of long term chronic direct toxic effects. They are however associated with a significantly increased risk of some untoward events such as hip fractures which are twice as common in elderly people on long acting sedatives than an age matched population. Also, elderly people admitted to hospital who are on benzodiazepines are twice as likely to develop cognitive impairment during their hospital stay than elderly patients not on benzodiazepines.
The major element of secondary prevention is to review the indication for use of benzodiazepines in the first place. There are a relatively small number of accepted indications for the use of these drugs, there are very few accepted indications for long term use and there are a number of controversial indications.
There is general agreement that benzodiazepines are useful in alcohol withdrawal, and of course some of them are effective anticonvulsants. The benzodiazepines also appear to be helpful in muscular spasm particularly in cerebral palsy and spinal cord disease.
Indications for long term use of these drugs are rather doubtful although probably chronic anxiety and insomnia are the commonest indications for prescribing them. It has been suggested that benzodiazepines are effective for the treatment of anxiety and insomnia for only 2 - 4 weeks after which the major reason for continuing their use is avoidance of withdrawal symptoms. Some degree of anxiety is of course normal in certain situations and actually improves concentration and intellectual performance. Use of sedatives in major psychosis or an agitated depression may be indicated but such treatment would always be in addition to specific treatment for the condition on the advice of a psychiatrist. This also applies to panic disorder which is a diagnosis which is probably made more frequently than it is actually present.
Although “normal” anxiety is agreed not to be an indication for benzodiazepine use dysfunctional anxiety which is maladaptive and associated with genuine psychological symptoms is considered to be quite a legitimate indication by some people. A study carried out by a group of British general practitioners however did show that a short counselling session was equally effective for this type of anxiety and did not take any more time.
Finally use of the drug for brief periods for insomnia, or for situational anxiety associated with some stressful event is really a matter of philosophy and is not really relevant in a discussion of the treatment of benzodiazepine dependence.
This subject would fill a textbook on its own, but the principles are:
As treatment continues the main modalities are:
Resource: DACAS Faxsheet 6.doc [46 KB]
These are only “core” programs. There are numerous “add ons” including relaxation training, pain management, and formal psychiatric treatment which may be needed to construct on individual programs for each patient.