Treatment of Alcohol-Related Disorder

Initial Assessment of Alcohol-Related Disorder

When presented with a patient with alcohol use disorder, it is crucial to conduct a thorough physical examination to identify any medical issues or comorbidities. Referral to a specialist is necessary if medical complications requiring treatment are detected. Assess psychiatric emergencies and address them promptly if present, considering the heightened risk of increased distress and other psychiatric emergencies.

Treatment Phases of Alcohol-Related Disorder

The treatment phases include three phases, namely, intervention, detoxification, and rehabilitation.

Intervention

• Utilize motivational interviewing and brief interventions to bring the patient face-to-face with the reality of their disorder.
• Emphasize the importance of recognizing the negative consequences of continued alcohol use.
• Display empathy, which is crucial in establishing rapport and understanding the patient's perspective.
• Acknowledge the potential need for multiple sessions and interventions for successful outcomes.
• They are cost-effective.
• Components that can be used when doing brief interventions are:

F - Feedback: Provide feedback on the risks associated with alcohol consumption.

R - Responsibility: Emphasize personal responsibility for change.

A - Advice: Offer advice on available treatment options.

M - Menu of Options: Present a menu of treatment options available to the patient.

E - Empathy: Demonstrate empathy during interventions.

S - Self-Efficacy: Emphasize the patient's ability to bring about change, enhancing self-efficacy.

Detoxification

Detoxification is employed to manage withdrawal symptoms. It is initiated if the patient is in a withdrawal state, addressing the physical aspects of alcohol dependence. Detoxification is a critical aspect of managing patients with alcohol use disorder, primarily focusing on treating withdrawal symptoms.

1. Initial Assessment:

• Conducting a complete physical examination is the first step in detoxification management.
• This examination is to rule out serious medical disorders and comorbid substance use disorders, reducing the likelihood of severe alcohol withdrawal.
• Even when presented with mild withdrawal symptoms, a thorough physical examination helps identify potential risk factors, such as other substances being consumed.

2. Patient Advice:

• It is essential to advise the patient to prioritize rest, ensuring an adequate period of recovery.
• Emphasize the importance of proper nutrition during this period.
• Oral vitamin supplementation, particularly thiamine, is recommended. Thiamine holds significance in the detoxification process and will be discussed further.

Thiamine Supplementation:

Thiamine is a crucial vitamin to include in the detoxification process. Administering thiamine is essential to prevent deficiencies and associated complications during alcohol withdrawal.

3. Preventing Escalation:

• Detecting any medical issues or using other substances during the physical examination is paramount.
• Addressing these issues early on helps prevent the progression of mild withdrawal symptoms to more severe manifestations.
•  Early intervention and monitoring are important to prevent complications and ensure a successful detoxification outcome.

Management of Withdrawal Symptoms

Drug of Choice

• Alcohol withdrawal induces a hyperexcited state in the brain due to the absence of alcohol, a depressant.
• The drug of choice for managing alcohol withdrawal symptoms is benzodiazepine, chosen for its low cost and high safety profile.
• Benzodiazepines come in oral and parenteral forms, with options for:
  • Short-acting (e.g., lorazepam, oxazepam) 
  • Long-acting (e.g., chlordiazepoxide, diazepam)
  • The availability of benzodiazepines, especially in oral form, simplifies the management process.
• Aim of administering Benzodiazepines: To administer sufficient benzodiazepine to keep the patient calm and sedated.
  • Emphasis on mild sedation ensures the patient remains responsive and can be easily aroused for procedures or examinations.
• Benzodiazepine Dosage: Understanding the therapeutic dose equivalents of different benzodiazepines is crucial, especially when switching from oral to parenteral administration.
• According to the latest CTP (Clinical Pharmacology and Therapeutics) database, some important dose equivalents include:

• Regular monitoring of the patient's response to benzodiazepine is essential.
• If the patient is initially managed with oral benzodiazepines and later requires parenteral administration, knowledge of therapeutic equivalents helps in a smooth transition.
• Dose equivalents may vary across different references; therefore, consulting various sources is advisable for accuracy in dosing.

Mild to Moderate Withdrawal

Monitoring Mild Withdrawals

Patients may initially present with mild withdrawal symptoms, such as tremors and autonomic disturbances. Despite the apparent mild nature, continuous monitoring is vital, as these symptoms might escalate, especially in the presence of underlying medical issues or concurrent substance use.

Severe Withdrawal

Less than 3% of patients may experience delirium tremens. The Risk Factors for Severe Withdrawal:

• Concomitant medical problems are a significant risk factor for severe withdrawal.
• Identifying and correcting these medical issues is important for effective management.
• Prevention is key in managing delirium tremens.
• When patients present with mild to moderate withdrawal and concomitant medical conditions, proactive management can decrease the likelihood of progressing to delirium tremens.

Benzodiazepines as First-Line Treatment: In cases of delirium tremens, benzodiazepines remain the drug of choice. Higher doses may be required, and treatment schedules can vary based on patient acceptance. In addition to benzodiazepines, a high-calorie, high-carbohydrate diet and multivitamins are essential in managing severe withdrawal.

• Use of Antipsychotics:
  • Antipsychotics like haloperidol may be considered in cases of severe agitation and hallucinations.
  • Caution is advised due to the potential decrease in seizure threshold with antipsychotic use.
• Alternative Options for Non-Responsive Cases:
  • For cases not responding to benzodiazepines, experienced clinicians in ICU settings may consider arousable deep sleep with propofol or dexmedetomidine (alpha 2 agonist).
  • This approach involves high initial doses followed by tapering.
  • Physical restraints may be required in managing delirium tremens, but they pose risks due to potential exhaustion.
  • A seclusion room might be a safer alternative in uncontrollable situations
• Warm Supportive Therapy:
  • Warm and supportive therapy is essential for delirium tremens patients who are often anxious and frightened.
  • Effective communication and support play a crucial role in the assessment and management of these patients.
• Seizures in Withdrawal:
  • Seizures may occur in approximately 1% of patients experiencing severe alcohol withdrawal.
  • A thorough physical and neurological examination is important in assessing patients presenting with seizures.
  • There is no need for anticonvulsants if the seizures are alcohol-related.
  • The primary choice of treatment for alcohol-induced seizures remains benzodiazepines.
  • A comprehensive neurological assessment is essential to rule out other neurological conditions that may require specific treatment.
• Delirium Tremens: In delirium tremens management, three key references are notable. 

1. The NICE guidelines (CG100 update 2017) recommend lorazepam (oral or IV). 
2. New south Wales (NSW) guidelines prefer diazepam
3. The New England Journal of Medicine review outlines protocols for both lorazepam and diazepam.

To read about Protracted Withdrawal and different Symptom Scales, sign up for the residency psychiatry program on the prepladder app.

Rehabilitation

Long-term and short-term goals are established in a rehabilitation program. The rehabilitation process aims to address both the psychological and social aspects of alcohol use disorder. Rehabilitation in the management of substance-related disorders comprises three essential components.

Rehabilitation is divided into two stages: the early intensive and long-term. It is emphasized that rehabilitation is an ongoing, continuous process.

Family involvement is stressed as beneficial during therapy, and patients are encouraged to bring a close family member for added support. Individual counseling and group sessions are designed based on the patient's scenario, and avoiding unnecessary psychotropic drugs is recommended unless there is a concurrent psychiatric disorder. Encouraging patients to join self-help groups, such as Alcoholics Anonymous, is seen as beneficial for long-term outcomes. The patient should be informed of the availability of these self-help groups as a valuable resource for ongoing support and intervention.

Counseling

One crucial component of rehabilitation is counseling, primarily based on Cognitive Behavioral Therapy (CBT).  This form of counseling extends over several initial weeks and continues throughout rehabilitation. The main focus of counseling revolves around 

1. addressing day-to-day life issues and Small daily triggers and challenges that can impact the patient's motivation for abstinence and may lead to relapse. 
2. Discussing these daily issues is essential, and the goal is to help the patient develop coping skills to manage life stresses effectively.

Whether inpatient or outpatient, counseling sessions can be individual or group-based. The frequency of sessions is adjusted to the patient's needs. In the initial phase, sessions may occur more frequently, such as three times a week for the first two to four weeks. Subsequently, sessions can be adjusted to once a week for the next three to six months, depending on the patient's availability and feasibility. Assessing and improving the patient's coping skills is a key aspect of counseling. 

Relapse Prevention in Alcohol Related Disorder

Another critical aspect of rehabilitation is relapse prevention. Relapse prevention involves identifying situations that increase the risk of relapse and actively working to prevent them. It is essential to recognize that relapse is not uncommon; it is a trial-and-error process as patients learn to navigate challenging situations without resorting to substance use.

Empathy is important when addressing relapses, as slips or instances of substance use can serve as valuable cues to identify high-risk situations. Rather than being judgmental, it is important to approach relapses with understanding, using them as opportunities to refine the patient's coping strategies.

The process of relapse prevention is ongoing and involves helping patients cope with stressors or triggers that may lead to relapse. For example, if a patient reports consuming alcohol in response to workplace stress, identifying such triggers allows for targeted intervention to enhance coping skills. Understanding that relapse prevention contributes to the development of better-coping mechanisms, the emphasis is on continuous support and training to empower patients to navigate challenging situations effectively. It underscores the importance of an ongoing and dynamic approach to treatment.

Medications in Alcohol-Related Disorder

1. Acamprosate

Acamprosate, an analog of the neurotransmitter taurine, influences metabotropic glutamate receptors, GABA, and NMDA receptors. By modulating the reward pathway, it decreases the craving for alcohol, making it valuable in managing alcohol-related disorders. Alcohol increases GABA and decreases glutamate; similarly, acamprosate mimics this effect, often referred to as artificial alcohol. It alleviates withdrawal symptoms, including mild anxiety, mood swings, and sleep difficulties associated with protracted withdrawal syndrome.

For a person weighing over 60 kgs, the recommended acamprosate dose is 1998 mg daily, given as 2 tablets of 333 mg twice daily. 

• In moderate renal impairment (creatinine clearance 30-50 mL/min), the dose is reduced to 333 mg thrice daily.
• When a person weighs less than 60 kg, the dosage is 1332 mg daily, consisting of 4 tablets of 333 mg. 

Acamprosate initiation should follow alcohol cessation. Treatment duration is six months, although it can be extended based on perceived benefits according to the NICE guidelines.

Side effects of acamprosate use:

• GI disturbances
• Headache
• Backache
• Infection, Flu-like symptoms
• Drowsiness

Serious adverse effects include

• Anxiety
• Depression
• Suicidal attempts
• Acute renal failure
• Heart failure
• Mesenteric arterial occlusion
• Cardiomyopathy
• Deep thrombophlebitis
• Shock

Precautions to Acamprosate use

Some precautions need to be taken before starting Acamprosate as it falls under category C for pregnancy, and precautions should be taken in cases of moderate renal impairment or comorbid depression and suicidality.

Contraindication of prescribing acamprosate

Severe renal impairment (creatinine clearance ≤30 mL/min). Vigilance is advised in adjusting doses for renal impairment and monitoring for depressive symptoms or suicidal tendencies during acamprosate therapy.

2. Naltrexone

Naltrexone, the second drug used in alcohol use disorder rehabilitation, is an opioid receptor antagonist with a prolonged action. It reduces activity in the ventral tegmental reward area, blocking pleasurable effects and decreasing craving, thus improving clinical outcomes. The recommended oral dosage is 50 mg/day, often initiated at 25 mg for the first two days to monitor for side effects. Duration can be six months or longer, with cessation advised for patients who continue drinking four to six weeks after initiation, according to NICE guidelines.

Side effects of naltrexone include:

• Abdominal symptoms
• Dizziness
• Headache
• Anxiety
• Fatigue

Some serious adverse reactions of naltrexone

• Severe withdrawal in opioid-dependent individuals
• Hepatotoxicity

Precautions for taking naltrexone

• Evaluating opioid use
• Considering hepatic or renal impairment
• Assessing a history of suicide attempts
• Caution in patients requiring opioid analgesics.

Contraindications of Naltrexone

• Current opioid use or withdrawal
• Anticipated need for opioid analgesia
• Acute hepatitis, or liver failure

3. Disulfiram

Disulfiram, often used as an aversive agent in alcohol use disorder treatment, works as an alcohol-sensitizing agent, creating unpleasant symptoms when combined with alcohol consumption.

Mechanism of action of disulfiram

• Irreversibly inhibiting aldehyde dehydrogenase, an enzyme in ethanol metabolism. 
• When a patient taking disulfiram consumes alcohol, acetaldehyde levels rise, causing adverse reactions like nausea, vomiting, and burning sensations.
• Disulfiram is considered an aversive or deterrent agent, discouraging patients from consuming alcohol due to the discomfort associated with the disulfiram-alcohol reaction.
• A disulfiram consent form is commonly used in hospitals. It outlines the treatment's details and obtains the patient's agreement before initiating therapy.
• Another mechanism involves disulfiram inactivating enzymes like dopamine beta-hydroxylase, reducing the rewarding effects of alcohol and cocaine in individuals addicted to both substances.
  • Inhibiting dopamine beta-hydroxylase may lead to increased dopamine levels, contributing to psychotic symptoms as a potential side effect of disulfiram therapy.

Disulfiram Alcohol Reaction

Duration of disulfiram

Standard treatment guidelines suggest a duration of one year.

Common Side Effects of disulfiram use

• Metallic aftertaste
• Dermatitis
• Halitosis

Precautions to disulfiram use

• High impulsivity: Caution is required due to the risk of disulfiram-alcohol reactions.
• Psychosis: Disulfiram can lead to psychotic symptoms.
• Current or history of:
  • Diabetes
  • Epilepsy
  • Hepatic dysfunction
  • Hypothyroidism
  • Rubber contact dermatitis

Contraindications to disulfiram use

• Concomitant alcohol use: Should be avoided at least 24 hours after the last alcohol consumption.
• Use of alcohol-containing preparations or metronidazole.
• Coronary artery disease, severe myocardial disease, diabetes, hypertension, stroke, cerebral thrombosis, and related conditions.

Alcoholics Anonymous(AA) in Rehabilitation

Alcoholics Anonymous is a Self-help group that follows a 12-step approach to alcohol cessation. It has a large Support Structure that includes Members. These members have access to help 24/7. They associate with a sober peer group for continuous support. The group encourages a change in drinking habits and lifestyle optimization.

Preventing Relapse is one of the main objectives of groups like Alcoholics Anonymous. It Encourages association with people maintaining sobriety. AA observes the accomplishments of sober group members and Acts as a support system to prevent relapse.

AA is associated with improved outcomes as it Encourages and inspires individuals on their journey to sobriety.

Frequently Asked Questions: 

Q: What is the drug of choice in delirium Tremens?

Answer: Benzodiazepines

Q: What drug reduces the craving for Alcohol?

Answer: Acamprosate

Q: Which drug is known to cause aversion to alcohol?

Answer: Disulfiram

Hope you found this blog helpful for your Psychiatric Theory and Specialities Preparation. For more informative and interesting posts like these, keep reading PrepLadder’s blogs.