CEP Workbook Module 6 Management 2

Fraser Todd & Michelle Fowler 2013

This workshop is provided through the Mental Health Education Resource Centre and supported by the Canterbury District Health Board. It is one of a series of workshops designed to help practitioners and services improve their capability to work with people experiencing complicated and complex mental heath problems. The material presented in this workshop is drawn from Te Ariari o te Oranga (Todd 2010), though is updated here in several areas. Copyright is asserted by Fraser Todd over the content. It may be freely used with permission. The name Te Ariari o te Oranga means the dynamics of well -being. The name was coined by that staff ad students of Te Ngaru Learning Systems, was given to a series of bicultural training events on co-exiting and mental health and substance use problems (CEP) over the past decade, and given to the document Te Ariari o te Oranga: The Assessment and Management of Co-existing Mental Health and Substance Use Problems (Todd 2010) by Paraire Huata. As a term, it captures the practice and teaching of CEP in New Zealand where bicultural approaches are honoured.

Welcome to this Workshop

This workshop on Assessment of CEP is the third of six advanced workshops. The relevant section in Te Ariari o te Oranga is essential background reading and much of that content will not be repeated in the workshop.

The MHERC CEP Workshop Series

Workshop 1: 1a. Introduction to CEP for frontline staff 1b. Introduction to CEP for managers Workshop 2: Recovery and Wellbeing Workshop 3: Motivation and Engagement Workshop 4: Assessment Workshop 5: Management I Workshop 6: Management II Workshop 7: Integrated Care To attend workshops 2-7, it is expected that participants will have either attended module 1 OR completed a self-directed learning package based on Workshop 1. It is essential that they are conversant with the generic principles that will be the focus of Workshop 1.

Workshop Overview
Management Part One Phases/stages of treatment and stage of change for problems Structured and comprehensive management plan from formulation Address Trans-diagnostic/common factors Structure of sessions

Management Part Two Use of generic and specific strategies Clinical case management Combining evidence-based practices for different diagnosis and problem Withdrawal management

Learning Intentions
Participants will be provided with the opportunity to: Gain a broader knowledge of management planning for tangata whaiora presenting with CEP Be able to implement combining evidence-based practices for working with different presentations Be able to plan and implement structured sessions for working with people with CEP Have a broad understanding of withdrawal management in working with people with CEP

Te Whare o Tiki Management

In addition, we will aim to cover some of the management components of the CEP Skills Framework Te Whare o Tiki. Te Whare O Tiki has been produced by Matua Raki to provide guidance and direction for learning and practice development in CEP.
Management is the fifth domain of the skills set and includes the following skills at three levels of competence, foundation, capable and enhanced: 6.1 Integrated treatment approach for CEP 6.2 Relapse prevention Strategies (RP) 6.3 Harm reduction and self-harm reduction strategies 6.4 Mental health or CEP crisis

6.5 Assessment and management of intoxicated states 6.6 Management of acute and protracted withdrawal states 6.7 Pharmacological treatments for mental health and substance use disorders 6.8 Psychological treatments including talking therapies such as Motivational Interviewing, Cognitive Behavioural Therapy, Dialectical Behavioural Therapy, group, systemic and family therapy. 6.9 Physical treatments e.g ECT, Transcutaneous Magnetic Stimulation 6.10 Self-help approaches 6.11 Pregnancy 6.12 Mental health, substance use and gambling disorders across the lifespan 6.13 Co-existing physical health conditions 6.15 Nicotine dependence 6.16 Legislative Requirements

Background Reading
Reading and knowledge to support this workshop can be found in the relevant chapters of Te Ariari o te Oranga. This workbook will include further information where there are updates to the content of Te Ariari.

Workshop Outline
Mihi and Introductions Housekeeping Workshop overview Introductory Mindfulness Exercise Withdrawal Psychological Interventions Pharmacotherapy Action Planning

Exercise 1: Mindfulness Introduction Instructions will be given in the workshop.

Review of Treatment Planning

Principles Harm Reduction Phases and Stages Structuring Treatment planning to treatment session structure stuff Specifics Withdrawal management Level 1 Interventions - Diagnoses Level 2 Interventions Symptoms and Key Factors (aetiological, transdiagnostic, amplifiers

Rachel Formulation
Pattern:

Vulnerability and Triggers: From what you have told me it appears that you may have some genetic predisposition to substance use disorder and social anxiety. On top of this you also had traumatic experiences while you were growing up such as abandonment and sexual abuse. This appears to have led to experiences of

Maintaining: It appears your alcohol use Distressing emotions feelings you have been experiencing for a long time\ However facing you have been experiencing

your distress and emotions without worsening the symptoms of depression without worsening the symptoms of depression as well as preventing you from achieving your life goals. Strengths: However, I also hear that you are motivated to make some changes by coming here and taking these steps, which isnt easy. You are in good physical health and you were able to be abstinent while you were pregnant which demonstrates being a good mum and meeting the needs of your daughter and the connections with your family is important to you. I heard you talk about having hope in your future, which is great! This will help you stay focused on your studies and future recovery.

Rachel Goal Setting for early and moving to middle treatment phases

Wellbeing Risk and safety self, others, child, AOD related harms Improve mood Manage withdrawal alcohol, cannabis, nicotine Coping skills anger, emotional regulation Psycho-education regarding illnesses Education Encourage and support social work studies Support networks PTSD address rumination, intrusive memories, hyper-arousal Spiritual identity,

Structuring 1:1 Treatment

1. Enhance motivate and set agenda (5 minutes) 2. Review (10-15 minutes) o Goals o Review past week o Review symptoms and goals o Review homework tasks and treatment adherence 3a. Specific Interventions: (10-20 minutes) 3b. Specific Interventions: (10-20 minutes) Specific interventions include: Amplifiers; skills that amplify specific interventions e.g. mindfulness, MI, Distress tolerance, Sensory modulation Interventions for specific problems: CBT, withdrawal management, relapse prevention, Positive Interventions 4. Review session and reinforce Commitment Talk & Wellbeing talk (Values, Wellbeing vision, (10 minutes)

3a

3b

Reflective listening and other motivational change enhancement techniques when change talk arises, and when well-being talk is identified.

1. Session 1

2.

3a.

3b.

4.

Review

Session 2 Review

Session 3 Review

Session 4

Enhance Motivation

Set homework Review Review Session

Session 5

Set session agenda

Review Enhance Commitm ent and Wellbeing Talk

Session 6 Review

Session 7 Review

Session 8 Review

Review

Withdrawal Management
The material provided has been obtained from the following resources produced by Matua Raki (2011). For more detailed information please refer to these guidelines. Matua Raki. 2011. Substance Withdrawal Management: Guidelines for medical and nursing practitioners in primary health, specialist addictions, custodial and general hospital settings. Matua Raki, Wellington. Matua Raki. 2011. Substance Withdrawal: Management guidelines for addiction and allied services. Matua Raki, Wellington.

Withdrawal
Withdrawal is used to describe the process and the acute symptoms, physical and psychological, that can accompany the cessation or reduction of use of any substance that has been used regularly over a prolonged period of time. The purpose of withdrawal management is to ensure the safety of the person, and others, as they stop or reduce substance use, and where possible to address withdrawal symptoms to alleviate acute distress. Withdrawal occurs in substance-dependent people who stop or considerably reduce their drug use. The diagnosis of dependence is generally required to understand and manage drug withdrawal.

DSM-IV Definitions
The Diagnostic and statistical manual of mental disorders, fourth edition (DSM-IV) contains the following definitions:

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Substance dependence: A maladaptive pattern of substance use, leading to Clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period: (1) Tolerance: as defined by either of the following: (a) A need for markedly increased amounts of the substance to achieve intoxication or desired effect (b) Markedly diminished effect with continued use of the same amount of the substance (2) Withdrawal: as manifested by either of the following: (a) The characteristic withdrawal syndrome for the substance (b) The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms (3) The substance is often taken in larger amounts or over a longer period than was intended (4) There is a persistent desire or unsuccessful efforts to cut down or control substance use (5) A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects (6) Important social, occupational, or recreational activities are given up or reduced because of substance us (7) The substance 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 the substance Appropriate withdrawal management planning depends on an accurate assessment of the persons: patterns of substance use; what, how much, how often and last use withdrawal risks, risks to self and others, history of withdrawal co-existing problems; mental and physical health support systems; family, whnau and friends motivation; goals and resilience setting safety external sources of stress

It may be necessary to provide withdrawal management in a wide range of settings, from the persons own home to general practice, general hospitals, police cells and prisons. Many people will stop or reduce substance use by choice while others will have this imposed on them through admission to hospital or prison. In the latter two situations people may not disclose substance use or may not be aware of the risk of withdrawal themselves. This can also be true when people present in a general practice or a general hospital setting. To provide appropriate care clinicians across a range of disciplines will need to be able to recognise the features of withdrawal from a range of substances and tailor responses accordingly.

Withdrawal Management Settings

(Matua Raki. 2011. Substance Withdrawal Management: Guidelines for medical and nursing practitioners in primary health, specialist addictions, custodial and general hospital settings. Matua Raki, Wellington. Pg. 7) Can include: Community home based withdrawal management: Monitoring can be provided by, specialist withdrawal practitioner or GP within the home environment. Social or respite service based withdrawal management: Provide a safer, supervised environment away from community and peer influences. Staff members are available for support and encouragement twenty-four hours a day. Specialist nursing and medical staff members are available on call for consultation. Social withdrawal management beds: Beds have been made available in residential treatment services nationally to assist those with

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methamphetamine dependence to have time out as a one-off opportunity or a lead-in to residential treatment. Inpatient medical withdrawal management: Can include specialist inpatient withdrawal management services or Hospital based withdrawal. These services are appropriate for people with severe problematic dependent substance use and or complicating factors. Factors affecting severity and risk of withdrawal: There is considerable variation in the severity of withdrawal. This will be determined by the following: Intensity of use Type of use Dose, frequency and duration of use Mode of administration Other substance use Co-existing mental health problems Co-existing physical health problems i.e hypertension, diabetes A history of high risk or withdrawal related seizures A history or apparent withdrawal related complications such as dehydration Risks to the individual or community Environment and psychosocial supports.

An accurate consumption history should record for each substance (whether prescribed or not) the following: Recent pattern and average daily consumption. Quantity of alcohol and drugs previously taken Frequency, duration and pattern of use Date, time and amount of last use Route of administration (oral, inhale, inject, snort) For prescribed medications, also record prescribed dose and prescribing doctor Whether they have successfully stopped in the past Whether they have experienced withdrawal symptoms in the past Current co-existing (mental or physical) health problems Any medical problems (epilepsy, seizures, allergies, diabetes) Mental health history with current mental health status and any medication

General Risks of Stopping Substances

Matua Raki. 2011. Substance Withdrawal Management: Guidelines for medical and nursing practitioners in primary health, specialist addictions, custodial and general hospital settings. Matua Raki, Wellington. (Pg 23) exacerbation of co-existing mental health or physical problems low mood and suicidality anxiety and panic attacks irritability and anger aggression disturbed sleep and insomnia confusion dehydration due to vomiting and or diarrhoea elevated blood pressure arrhythmias

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delusions and psychosis hallucinations brain damage seizures death

Generally acute substance withdrawal is not life threatening or physically risky unless the person has been using alcohol, benzodiazepines, gamma-hydroxybutyrate (GHB) and/or inhalants heavily and regularly over a prolonged period of time and/or has a history of previous severe withdrawal. The seriousness of the risks involved with withdrawal from these substances indicates a greater need for careful substance specific risk assessment and the involvement of specialist addiction services and/or medical providers. Suddenly stopping alcohol use may trigger: Nausea and vomiting Dehydration Seizures Hallucinations Heart problems Death Stopping benzodiazepine use may trigger: Panic attacks Seizures Hallucinations Confusion Death Stopping GHB use may trigger: Nausea and vomiting Seizures Hallucinations Muscle and kidney damage Heart problems Death Inhalant withdrawal is poorly understood but it appears that for some people stopping use of inhalants may trigger: Nausea Confusion Hallucinations Seizures

Common Withdrawal Symptoms

On stopping AOD use, whether this is voluntary or enforced such as entering residence, the Withdrawal Syndrome on average lasts 7-10 days, depending on the substance. The withdrawal syndrome usually peaks between days 2-4 when the worst symptoms occur. Common Psychological Symptoms Common Physical Symptoms

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Agitation, irritability, anger Moodiness, mood swings or feeling low Anxiety, worries Restlessness and inability to sleep Difficulty concentrating and fidgety Tiredness and low in energy Craving (hanging out) and strong urges to use

Sweating, goosebumps, feeling hot or cold Cold or flu-like symptoms Loss of appetite, feeling sick, stomach cramps, vomiting Aches and pains Feeling shaky and shivery Increased heart rate Headache Insomnia

Alcohol Withdrawal
Matua Raki. 2011. Substance Withdrawal Management: Guidelines for medical and nursing practitioners in primary health, specialist addictions, custodial and general hospital settings. Matua Raki, Wellington. (Pg 10-20)

Assessment:
A comprehensive assessment is the first step in managing withdrawal with the priority being to identify and define any risks. A specific alcohol use history also includes: type and strength (% alcohol per volume) currently using time of last drink average number of standard drinks (STDs) a day over time any drinking soon after waking needing to control shakes by using alcohol past history of seizures past history of hallucinations co-existing physical health problems current goals relating to use

Management of Alcohol Withdrawal

Monitoring of withdrawal requires ongoing assessment and clinical judgment. It is best for the person requiring alcohol withdrawal to be referred to GP, or specialist addiction services for appropriate monitoring and management. The revised CIWA-Ar provides a structured format to record the severity of withdrawal symptoms. Alongside its usefulness in initial assessment of withdrawal symptoms the CIWA-Ar can be used to monitor changing withdrawal symptoms and the efficacy of withdrawal management over time. Withdrawal management setting: Community withdrawal management: Mild to moderate withdrawal Where community based home detoxification and withdrawal management services are available the majority of people withdrawing from alcohol, particularly those with low to moderate CIWA-Ar scores, can safely be managed and cared for in their own homes or in supported accommodation.

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In-patient withdrawal management: Severe withdrawal The availability of 24 hour specialist nursing and medical supervision allows for the safer management of risk associated with alcohol withdrawal than in a community setting. This is particularly true for people with a known history of severe withdrawal, seizures and CIWA-Ar scores over 15.

Medication Management
Thiamine 100mg daily up to three times a day for people withdrawing from alcohol Diazepam reducing regime depending on severity of withdrawal. For mild to moderate withdrawal regime is usually over 5-7 days

Matua Raki. 2011. Substance Withdrawal: Management guidelines for addiction and allied services. Matua Raki, Wellington. (Pg. 8)

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Alcohol Withdrawal Complications

Hallucinations occur in 25% of people with severe alcohol dependence are generally more common in the first 48 hours but can occur up to day five are usually visual and tactile and are occasionally auditory can occur while the person is still orientated without delirium Seizures occur in 15% of people with severe alcohol dependence risk increases to 70% if person has had a previous withdrawal seizure generally occur within the first 48 hrs are the grand mal type of seizure are usually one or few in number Delirium tremens (DTs) Delirium tremens is the most severe form of alcohol withdrawal syndrome and is a medical emergency. In people who are severely dependent delirium tremens typically occurs after two to five days of untreated severe withdrawal syndrome, though mild or moderate withdrawal symptoms may not precede delirium tremens. Features include: fluctuations in blood pressure or pulse disturbance in fluid balance/electrolytes/hyperthermia gross tremor paranoid ideation confusion and disorientation extreme agitation or restlessness Wernickes encephalopathy: Wernickes encephalopathy is a brain injury resulting from a deficiency in vitamin B1. If not treated rapidly it can lead to permanent brain damage and memory loss. Symptoms of Wernickes encephalopathy include: confusion nystagmus, with or without opthalmoplegia (blurred vision) ataxia peripheral neuropathy (can be present in up to 80% of people with Wernickes encephalopathy) Thiamine should be prescribed and offered as an oral medication to people at high risk of developing Wernickes encephalopathy: the malnourished or at risk of malnourishment those with decompensated liver disease in acute alcohol withdrawal before and during planned alcohol withdrawal

In acute need intravenous or intramuscular thiamine can be given

Cannabis Withdrawal
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Matua Raki. 2011. Substance Withdrawal Management: Guidelines for medical and nursing practitioners in primary health, specialist addictions, custodial and general hospital settings. Matua Raki, Wellington. (Pg 35-40)

Assessment
A comprehensive assessment is the first step in managing withdrawal with the priority being to identify and define any risks. A specific cannabis use history includes: quantity of use, amount consumed, type of cannabis and potency duration, pattern and frequency of use mode of administration (smoked or eaten, mixed with tobacco) time and amount of last use past history of aggression and violence goals relating to use

Management of Cannabis Withdrawal

People wanting to withdraw from cannabis should be provided with a menu of intervention options. This may include the choice of sudden cessation, with or without symptomatic medication or a supported gradual reduction using psycho-social interventions. Comprehensive assessment, treatment planning and supportive counseling are the main strategies for managing cannabis withdrawal for the majority of people and can be safely provided in the community. Medication and or admission into a social withdrawal management service are rarely required apart from those people with co-existing problems, including other substance use, a history of aggression and or inappropriate home environments.

Medication Management
To date no specific pharmacotherapy has been proven to significantly help with managing cannabis withdrawal. Atypical antipsychotic medication, (e.g. quetiapine, has been used to help manage agitation, anxiety and sleep problems in cannabis withdrawal. There is no evidence to date to support this practice apart from anecdotal reports of efficacy. Use of antipsychotic medication for this purpose should be only considered in consultation with an addiction medicine specialist, physician or psychiatrist. Benzodiazepines (e.g. diazepam) may help with managing very severe withdrawal symptoms such as extreme anxiety, agitation, irritability and aggression and prolonged sleep difficulties. This however needs to be managed under supervision from a specialist addiction service.

Risks Associated with cannabis withdrawal

cannabis withdrawal is not physically dangerous most people will complete withdrawal with relatively mild symptoms a past history of violence and aggression may indicate a risk of aggressive behaviour which could place other people at risk underlying mental health issues may be unmasked during withdrawal suicidality and self injury may be a risk factor for people with a co-existing mood or psychotic disorder people with severe withdrawal symptoms and or co-existing problems may require appropriate medication

Onset and Duration of Withdrawal 18

Onset of cannabis withdrawal usually occurs one to two days after last use. Most symptoms peak between days two and six. It is important to note that withdrawal severity and duration will be dependent on the individual and the following variables: the amount, frequency and strength of cannabis used duration of current patterns of use stopping suddenly or reducing levels of use over time other substance use co-existing mental health problems co-existing physical health problems including chronic pain history of aggression or violence outpatient or inpatient setting see tables on next page

Exercise 2: Rachel: Withdrawal In small groups: Review the case of Rachel if you need to What symptoms of withdrawal do you think Rachel will experience? Over what time period? Describe in detail the specific steps you will take to manage her withdrawal symptoms

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Matua Raki. 2011. Substance Withdrawal: Management guidelines for addiction and allied services. Matua Raki, Wellington, Pg. 12

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CADS ALCOHOL WITHDRAWAL SCALE (CIWAA-R)

Please enter information or affix Patient Information Label

MRN Surname Given names D.O.B. ______________ Dr _________________

Sex _______ Ward ________

PROTOCOL FOR THE USE OF CLINICAL INSTITUTE WITHDRAWAL ASSESSMENT FOR ALCOHOL REVISED VERSION (CIWAA-R)
Alcohol Withdrawal Monitor the patient hourly for at least 4 hours using the CIWAA-R Contact the MO for assessment if: a) The alcohol score increases by least 5 points over the 4 hour period, OR b) The CIWAA-R total score reaches 10 or more

MANAGEMENT OF ALCOHOL WITHDRAWAL

The management focuses on five major problem areas: 1. 2. 3. 4. 5. 6. Progression to severe withdrawal, thus providing medication for withdrawal syndrome Risk of injury to self or others or self-destructive behaviour due to altered mental state Risk of dehydration, electrolyte and nutritional imbalances Potential for seizures Presence of concurrent illness which masks or mimics withdrawal To prevent Wernickes encephalopathy with thiamine administration

NURSING ACTIONS
Monitor the patients withdrawal status daily for usually 5-7days however may be up to 14 days Regular and frequent observations of patients temperature, pulse rate, blood pressure, respiratory and level of hydration. Monitor BAL to prevent risks of combining medication with alcohol Tailor Medication regime as needed by the client without over sedation. Assess effectiveness of medication daily and need for medical review Nurse in a low stimulus environment Slow, steady non threatening approach Reassure frequently, tell the patient the symptoms will pass Explain perceptual errors Frequent reality orientation Ensure patient safety Restore and maintain metabolic and nutritional equilibrium

References:
NSW Detoxification Clinical Practice Guidelines NSW Health 1999.

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Please enter information or affix Patient Information Label

ALCOHOL WITHDRAWAL ASSESSMENT

Date_________________
TIME Pulse B.P. Temp Item 1 2 3 4 5 6 7 8 9 10 score Sedation Type Dose TotalDose

MRN Surname Given names D.O.B. ______________ Dr _________________

Sex _______ Ward ________

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

WITHDRAWAL SEVERITY:

Mild <10:

Moderate 10-20:

Severe 20+

Date___________
TIME Pulse B.P. Temp Item 1 2 3 4 5 6 7 8 9 10 score Sedation Type dose TotalDose

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

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CLINICAL INSTITUTE WITHDRAWAL ASSESSMENT FOR ALCOHOL-REVISED VERSION (CIWAA-R) Item 1 Nausea and vomiting Item 2
0. 1. 2. 3. 4. 5. 6. 7.

Tremor
No tremor Not visible, but can be felt fingertip to fingertip Moderate, with patients arms extended

Ask do you feel sick to your stomach? Have you vomited? and observe 0. No nausea and no vomiting 1. Mild nausea with no vomiting 2. 3. 4. Intermittent nausea with dry heaves 5. 6. 7. Constant nausea, frequent dry heaves and vomiting

Observe patients arms extended and fingers spread apart.

Severe, even with arms not extended

Item 3
0. 1. 2. 3. 4. 5. 6. 7.

Paroxysmal sweats
No sweat visible Barely perceptible sweating, moist palms

Item 4

Anxiety

Beads of sweat obvious on forehead

Drenching sweats

Observe and ask, Do you feel nervous? 0. No anxiety, at ease 1. Mildly anxious 2. 3. 4. Moderately fidgety and restless 5. 6. 7. Equivalent to acute panic attack as seen in a severe delirium or acute schizophrenic reaction

Item 5
0. 1. 2. 3. 4. 5. 6. 7.

Agitation
Normal activity Somewhat more than normal

Item 6

Tactile disturbances

Moderately fidgety and restless

Paces back and forth during most of interview, or constantly thrashes about.

Ask, Have you any itching, pins and needles, burning or numbness. Do you feel bugs crawling on or under your skin? 0. None 1. Very mild itching, pins and needles, burning or numbness 2. Mild itching, pins and needles, burning or numbness 3. Moderate itching, pins and needles, burning or numbness 4. Moderately severe hallucinations 5. Severe hallucinations 6. Extremely severe hallucinations 7. Continuous hallucinations

Item 7

Auditory disturbances

Item 8

Visual disturbances

Ask Are you more aware of sounds around you? Are sounds harsh or frightening to you? Are you hearing anything disturbing or that you know is not there? Observe. 0. Not present 1. Very mild harshness or ability to frighten 2. Mild harshness or ability to frighten 3. Moderate harshness or ability to frighten 4. Moderately severe hallucinations 5. Severe hallucinations 6. Extremely severe hallucinations 7. Continuous hallucinations

Ask, Does the light appear to be too bright? Is its colour different? Does it hurt your eyes? Are you seeing anything that is disturbing you? Are you seeing things you know are not there? and observe 0. Not present 1. Very mild sensitivity 2. Mild sensitivity 3. Moderate sensitivity 4. Moderately severe hallucinations 5. Severe hallucinations 6. Extremely severe hallucinations 7. Continuous hallucinations

Item 9

Headaches, fullness in head

Item 10

Ask, Does your head feel different? Does it feel like there is a band around your head? Do not rate for dizziness or light-headedness. Otherwise rate severity. 0. Not present 1. Very mild 2. Mild 3. Moderate 4. Moderately severe 5. Severe 6. Very severe 7. Extremely severe

Orientation and clouding of consciousness

Ask, What day is this? Where are you?, Who am I? 0. Orientated and can do serial additions 1. Cannot do serial additions or is uncertain about the date 2. Disorientated for date by no more than 2 calendar days 3. Disorientated for date by more than 2 calendar days 4. Disorientated for place and/or person

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ALCOHOL WITHDRAWAL TREATMENT FOR SPECIALIST RESIDENTIAL UNIT OR HOSPITAL

SEVERITY WITHDRAWAL OF DIAZEPAM DOSAGE AND FREQUENCY

Mild withdrawal CIWAA-R <10 (old AWS = <4) Moderate withdrawal CIWAA-R = 10-20 (old AWS = 5-14)

Severe withdrawal CIWAA-R >20 (old AWS = >15)

Supportive care in the community. Observed by detox nurse once-twice daily Place on small dose diazepam regime. Detoxification nurse to assess if score indicates moderate alcohol withdrawal If alcohol withdrawal confirmed: give 10mg oral diazepam and observe more regularly, treat according to withdrawal score. Medical review after 60-80mg of diazepam given. The client will be admitted to hospital for severe withdrawal. If alcohol withdrawal confirmed: Medical officer will review and treat accordingly as per alcohol withdrawal protocol. Contraindications to diazepam: respiratory failure, significant livery impairment; possible head injury or cardiovascular accident. PRIMARY TREATMENT FOR SEVERE WITHDRAWAL CIWAA-R>20 The recommended regimen is oral loading doses of diazepam 20mg every 1-2 hours until: Symptomatic relief is obtained, or CIWAA-R score falls below 10, or The person in withdrawal becomes drowsy

ROUTINE PREVENTION OR WERNICKES ENCEPHALOPATHY Prophylactic Thiamine Treatment 100mg orally, up to three times per day for at least 1 week 100mg IV/IM for three days if severe withdrawal or Wernickes encephalopathy is suspected. Then oral doses indefinitely NB. Administer Thiamine before giving glucose, including food or sweet drinks. A carbohydrate load in the presence of thiamine deficiency risks precipitating Wernickes encephalopathy.

Age and body weight should be considered when prescribing diazepam. Lower doses may be more appropriate in slight individuals and the elderly (perhaps as little as 5mg). The maximum total dose of diazepam is generally 120mg over 24 hours, but in certain Situations this may still be insufficient to control withdrawal. Close specialist management is required for higher doses. If the maximum dose is reached, review of patients status and ensure that additional complication factors are not responsible for the CIWAA-R score.

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Level 1 Interventions: Diagnoses

The first level of treatment involves addressing diagnoses. In general the standard approach involves applying the usual treatments for each of the key treatments simultaneously in an integrated manner. In other words, with someone who has bipolar disorder and opiate dependence, the usual treatments for each would be combined into a single treatment package. This approach appears more effective than treating each problem separately or sequentially. However, it appears that there are seldom improvements in both mental health and substance use problems, and what improvements do occur seem modest at best for many. Stepped Care With respect to outcomes for people with CEP involving serious mental illness (for example chronic psychosis or moderate to severe bipolar disorder):

One third of people do well in treatment after 12 months (and they show indications of improvement early in treatment One third do not do well initially but are showing significant improvements after 10 years of treatment One third of people have shown little improvement 10 years after entering treatment.

This suggests it is reasonable to take a stepped care approach where standard treatments for diagnoses are used first, and for those not showing early signs of improvement within a few months, a more personalized and comprehensive treatment is then instituted. Even with stepped care, there are specific interactions between mental health and substance use issues that need to be considered.

Reasons for Substance Use in People with Mental Health Problems

The reasons why any individual uses substances vary from person to person and are very important to consider. In general, alcohol tends to be used for self-medication for anxiety symptoms and hyper-arousal, while cannabis tends to be used for enjoyment; for the hedonic experience i.e. for enjoyment. However, this tends to vary depending on the mental health problem, and people may use for both reasons. A functional analysis of the role of substance use for each individual is an extremely useful tool for indicating specific treatment approaches. This has been discussed in the assessment workshop.

Major Depression and Alcohol

Symptoms consistent with a major depressive episode are commonly present in those using alcohol heavily. In the majority of cases the depressive symptoms are secondary to alcohol use and will resolve starting within 2-4 weeks of stopping drinking. In many cases, the best treatment is to cease alcohol use and monitor improvements in mood. Where there is strong evidence that depression is a primary disorder (rather than secondary to alcohol use), it may be prudent not to wait for 2-4 weeks before starting treatment for depression, given that persisting depressive symptoms predict failure to stop drinking. Primary depression can often be indicated by considering age of onsets and family history

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(i.e. genetic vulnerability) of depression and substance use, and whether symptoms of depression have been present during periods of abstinence from alcohol. Persisting depressive symptoms increase the likelihood of alcohol relapse Persisting alcohol use is associated with a poorer response to treatment for depression. There is some evidence that SSRIs increase the risk of alcohol relapse in some people, probably through increasing impulsivity and therefore the likelihood of drinking when experiencing cravings, This effect appears most prominent in males with externalizing problems, related to receptor polymorphisms, probably of the opioid receptors. This effect may to be reduced by the addition of an opioid antagonist such as Naltrexone. There is some evidence that a combination of SSRI + Naltrexone is associated with a better outcomes for both alcohol use and depression in a range of people.

Treatment Recommendations: The evidence mentioned above is in its early stages and needs further elaboration. However, a reasonable approach to treatment would be as follows: Where there is a clear indication that depression is primary, initiate treatment for both depression and alcohol use (e.g. alcohol detoxification) early. Where it is unclear whether depression is primary or secondary to alcohol use, withdraw alcohol first and monitor mood for 2-4 weeks after stopping drinking. Initiate treatments for depression if there are no signs of improvement in mood after 2-4 weeks of abstinence In males with a history of externalizing problems, add combine Naltrexone if an antidepressant is to be used. In others with a primary depressive disorder as well as alcohol dependence, still consider antidepressant + Naltrexone Primary depression should be treated assertively and the goal should be complete resolution of symptoms. Consideration should be given to the use of rating scales for depression such as the Beck Depression Inventory in addition to the subjective impression of the clinician to monitoring of changes and improvements in depressive symptoms.

Major Depression and Cannabis

Most of the evidence available suggests that the high rate of co-occurrence between depression and heavy cannabis use is due to common underlying factors such as externalising behaviour problems that may have been present since an early age. However, there is a small amount of evidence that cannabis may be used in some people to self medicate symptoms of depression, and also that cannab is use may worsen depression. There is also some evidence that SSRI antidepressants interact with cannabis, possibly to reduce the effects of cannabis or to alter the effects in a way that makes cannabis use less enjoyable. Those with cannabis dependence appear to engage in treatment for depression less well than those without cannabis dependence. There is no evidence that cannabis use, at least at low to moderate levels, impacts on treatment for depression at all. In fact there is some evidence that it does not. There is therefore no rationale for insisting that cannabis use should be stopped before depression is treated.

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Treatment Recommendations: It is difficult to make specific evidence-based recommendations for treatment of major depression and cannabis use given that the research evidence is at its early stages. Anecdotal evidence indicates the following suggestions may be prudent: o With respect to the interaction between cannabis and depression, listen to the person and work with their reports of the interaction. o If an SSRI is being prescribed, watch engagement, motivation and adherence closely. So will reduce cannabis use due to possible interactions, but others will reduce or stop SSRI use. o Do not delay treatment for depression until cannabis use is stopped. There is no evidence to support this or to suggest it is a reasonable treatment approach. In fact it is more likely that treatment of depression will make cessation of cannabis use more successful. o If there is comorbid alcohol use, Naltrexone can be used but it may lead to an increase in cannabis use. This is not a contraindication to using Naltrexone, rather there needs to be increased efforts to educate and ensure cannabis use does not escalate. o Major depression is commonly comorbid with anxiety symptoms and disorders. The interaction between cannabis use and anxiety also needs to be considered in such cases.

Major Depression and Opioids

Major Depression occurs commonly in people with opioid dependence. While the presence of mental health problems appears a strong predictor of treatment seeking, depression also appears common in those who do not seek treatment for opioid dependence Anecdotal reports suggest that fluctuating daily doses of opioid contributes significantly to depressive symptoms Note also that the lifestyle and complications of opioid dependence, especially intravenous opioid use, are likely to contribute significantly to depressive symptoms Stabilisation on an opioid agonist such as methadone or buprenorphine is frequently associated with resolution of depressive symptoms For people with co-existing major depression initiating opioid agonist therapy, antidepressant medication does not appear to improve the symptoms of depression over and above stabilisation of opioid dose and lifestyle issues.

Treatment Recommendations: A reasonable approach in those with major depression and opioid dependence is to focus initially on stablisation of opioid does (either through opioid agonist therapy or withdrawal followed by abstinence based residential treatment) and to consider antidepressant treatment if depressive symptoms persist beyond the initiation period.

Bipolar disorder and Alcohol

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Alcohol appears to be most commonly used by people with bipolar disorder during the depressed phase. Alcohol use in bipolar disorder seems to be linked more to coping than pleasure Alcohol use is associated with instability in mood swings and poor treatment response for bipolar disorder For many with bipolar disorder, it is the mood instability that drives substance use and relapse onto substance. Assertive treatment of the bipolar disorder is an essential aspect of treating CEP involving substance use. Substance use problems are associated with an increased rate of cycling of bipolar disorder. There is a small amount of evidence that sodium valproate may be better than lithium in bipolar disorder with substance use, perhaps due to the increased rates of rapid cycling.

Treatment Recommendations: While it is essential to treat the alcohol use and to aim at least for a period of abstinence, the key is to treat the symptoms of bipolar disorder with a combination of medication, CBT, stabilization of social rhythms and strategies to reduce stress, especially interpersonal stress. Consider sodium valproate as first line medication for bipolar disorder Naltrexone should be considered though care needs to be taken to monitor liver function given the combined effects of alcohol, naltrexone and sodium valproate on liver function. However, while regular monitoring is advised, this should not be a contraindication.

Bipolar disorder and Cannabis

Cannabis appears to be most commonly used during periods of elevated mood. Self-reported reasons for cannabis use focus on the hedonic aspects or pleasure of intoxication It is likely that the dyscontrol that leads to cannabis dependence in people with bipolar disorder is that of abnormal mood (especially elevated mood) as much as intrinsic substance related dyscontrol Cannabis use is associated with elevating mood and inducing mania, and with increased psychotic symptoms in bipolar disorder Self-reports suggest that the impact of cannabis use on bipolar symptoms is quite variable. For some, cannabis may settle psychotic symptoms and elevated or depressed mood. For other it may worsen them. For many it may have little effect.

Treatment Recommendations: As with alcohol, the key with this combination of problems is to treat the bipolar disorder assertively. Aiming for abstinence early in treatment is often worthwhile and relatively easily achieved in comparison to other serious mental health problems.

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PTSD and Alcohol

Alcohol use in people with PTSD is frequently driven by hyperarousal A cycle involving intrusive memories, hyperarousal and rumination appears central to alcohol use Treating PTSD and alcohol at the same time is associated with better outcomes. Imaginal desensitisation is the treatment of choice for PTSD symptoms and should be introduced very early in the treatment process Given that many people who misuse alcohol have avoidant coping styles, it is prudent to precede imaginal desensitization with skills to help the person cope with anxiety. Mindfulness is useful for this especially given that is will also help reduce rumination. . While beta-blockers for PTSD symptoms is not supported by research, they may be worth trying in PTSD complicated by alcohol use given the central role of hyperarousal. There is a slight amount of research suggesting that antipsychotics, particularly risperidone may reduce hyperarousal, as might prazosin Emerging evidence suggests that disulphiram (antabuse) at lower doses may reduce anxiety and hyperarousal.

Treatment Recommendations: Use imaginal desenstisation early in treatment Complement this with strategies to reduce anxiety, such as mindfulness. Mindfulness should also be used to target ruminations that underpin hperarousal. Consideration should be given to the use of medication such as risperidone, beta-blockers or prazosin to reduce hyperarousal. Disulphiram may help reduce anxiety and hyperarousal as well as support abstinence from alcohol

PTSD and Cannabis

Evidence is emerging that the increased rates of cannabis use in people with PTSD are likely to be driven by self-medication and that cannabis use is driven mainly by its tendency to reduce intrusive memories and recollections. This is consistent with the known impact of cannabis on memory. Given the above, it is likely that any reduction in cannabis use may be followed by an increase in PTSD symptoms, especially intrusive memories and their consequences.

Treatment Recommendations: As with PTSD and alcohol use, treatment of PTSD symptoms should probably occur early.

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Given the impact of cannabis use on intrusive memories, it would be wise to target these with imaginal desensitization after coping skills for anxiety (e.g. mindfulness) have been briefly introduced. An SSRI may be helpful with respect to intrusive memories, and may help with the reduction in cannabis use

PTSD and Other Drugs

Both opioids and benzodiazepines in the doses used by drug users are likely to significantly improve anxiety symptoms related to past trauma which is common with these drugs of abuse. Trauma often precedes the onset of drug use, but additionally those using opioids and benzodiazepines have lifestyles and behavioural traits such as impulsivity that increase the likelihood of further trauma especially from interpersonal violence and motor vehicle accidents.

Eating Disorders
Both opioids and benzodiazepines in the doses used by drug users are likely to While there is an increased prevalence of substance use disorders in those with eating disorders, there appear to be few common factors that might explain this other than potential cognitive factors common to both A number of substances, particularly stimulants, may be misused to manage appetite and reduce weight Anecdotal reports suggest the cannabis may increase binge eating in some people.

Brief Psychological Interventions

Level 1 interventions mentioned above are interventions targeting particular diagnoses that are useful in stepped care approaches. Level 2 interventions are those that target problems and common underlying factors beyond simply applying generic approaches for diagnoses. These may include interventions for: o Issues likely to impede engagement o Amplifiers o Transdiagnostic (common underlying) factors While intensive psychotherapies are likely to be more effective than briefer psychotherapies, briefer interventions are more efficient and often simpler when they do work.

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Brief CBT (bCBT) is designed to target specific problems and to be undertaken in anything from approximately 20 minutes to one hour over 1-4 sessions Optimally, to undertake bCBT effectively clinicians should have good knowledge and experience of undertaking longer CBT treatments There are a range of psychotherapeutic approaches that appear to be equally effective in clinical trials. For example, with borderline personality disorders DBT, mentalization, schema therapy and CBT appear equally effective. For a range of problems CBT does not appear more effective than other structured interventions by the end of treatment, but unlike treatments CBT increase in effectiveness for a considerable period of time after the end of formal treatment.

Issues that Impede Engagement

Anxiety Anger and hostility

Amplifiers
Motivational interviewing Mindfulness Defusion Emotion regulation Coping skills and distress tolerance Relaxation skills o Progressive muscle relaxation o Deep breathing o Guided Imagery Behavioural activation

Psychological Transdiagnostic Factors

Self-esteem and self-efficacy Attention control Impulsivity Negative urgency Negative emotionality Cognitive and attentional bias Emotion regulation

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Rumination Perfectionism Avoidant coping style Insomnia

Overview of Cognitive Behavioural Therapy: The ABC Model

Assessing Behaviours, Problems and Precipitating Situations
Behaviour is shaped by antecedents and consequences. Activating Event/Antecedents o Events the precede a behaviour o May be an emotion, a physiological state, and action or a thought Behaviours o Any act, feeling or thought that follows the antecedent Consequences o Either positive (a pleasant experience or the removal of a negative experience) or negative (an unpleasant experience or the absence or removal of a positive experience) o Can be short (proximal) or long-term (distal)

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Identifying the Activating Events/Antecedents:

What were you feeling before you did that? (affect/emotion) What happens physically before this happens? (physical) How do you normally act before this happens? (behaviour) What thoughts go through your mind before this happens? (Cognitive) Where and when does it usually happen? (contextual) Does this happen with everyone or just with certain people? (relational)

Maladaptive Thoughts
Core schema are worth identifying but work on changing them is probably too complex for bCBT Chronic PTSD from trauma and low self-esteem may require intensive treatment beyond the scope of bCBT

Identifying Maladaptive Thoughts and Beliefs Guided discovery (Socratic questioning) Identification of automatic thoughts that occur in a session Brief explanations/mini lessons Readings and other resources Thought records Automatic thought checklists Computer-assisted CBT

Thought Record
Event Automatic Thoughts (Rate degree of belief 0-100%) Emotion (Rate intensity 0-100%)

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Automatic Thoughts Checklist

34

I should be doing better in life He/She doesnt understand me Ive let hi/her down I just cant enjoy things anymore Why am I so weak I always keep messing things up My life is going nowhere I cant handle it Im failing Its too much for me

I dont have much of a future Things are out of control I feel like giving up Something bad is sure to happen There must be something wrong with me

Wright J.H., Sudak, D.M. Turkington, D. Thase, M. High-Yield Cognitive Behavior Therapy for Brief Sessions: An Illustrated Guide American Psychiatric Publishing Washington 2010

Common Cognitive Distortions

1. 2. 3. 4. 5. 6. 7. 8. 9. 10. All or nothing thinking Overgeneralization Mental filtering Disqualifying the positive Jumping to conclusions Magnification or minimisation Emotional reasoning Should statements Labelling Personalisation

Exercise 3: Rachel Maladaptive Thoughts In small groups: Appoint someone to feedback to the class

35

What automatic thoughts, intermediate thoughts, core schema and cognitive distortions to you think Rachel is likely to have? Discussion

Drugs and Medications

Naltrexone
Opioid receptor antagonist Blocks the reinforcing effects of alcohol, reduces craving and dyscontrol, reduces risk and extent of relapse Under-utilised

Side Effects
Nausea, vomiting, reduced appetite Dizziness Pneumonia (serious) Liver damage at high doses (serious) Sedation in a minority

Dose
Patient should be opiate free for 7-10 days

36

50mg tablet Start 50mg daily, may increase Works within a few days, maximum effect after a few weeks Long acting injections available in US

Other information
Potential effects on foetus in animal studies (avoid at least in first trimester) Found in breast mile Warn previous IV drug users on naltrexone for opioid dependence of risk of loss of tolerance to opioids and potential overdose May be used with SSRIs, Antabuse

Drug-Medication Interactions
This appendix accompanies the text in section 4.6.4 of Te Ariari o te Oranga and is intended to be a guide to drug drug and drug medication interactions. Note that the absence of an interaction described here does not mean it does not exist and therefore the combination is safe.

Potentially Fatal Interactions

lorazepam and alcohol, which has been associated with significant respiratory and cardiac depression (this appears to be more likely with lorazepam than with other benzodiazepines) amyl nitrate and sildenafil (viagra) or tadalafil (cialis ), which have been associated with potentially fatal hypotension ecstasy and ritonavir, which has been associated with fatalities reported ecstasy and monoamine oxidase inhibitors, including moclobemide , which have been associated with fatalities amphetamines and monoamine oxidase inhibitors, including moclobemide , which have been associated with a severe hypertensive crisis.

Nicotine
Nicotine induces certain CYP450 enzymes and can increase the metabolism and reduces serum levels of a range of drugs,

Reduced blood levels may occur with the combination of tobacco use and the following drugs:
alprazolam and other benzodiazepines beta-blockers, especially propranolol caffeine

37

chlorpromazine clozapine (reduction in blood levels may be marked) corticosteroids haloperidol heparin inhaled insulin (currently unavailable; causes a significant increase in insulin levels, contraindicated in current or recent tobacco users) mexiletine olanzapine (mild effects, so may not need dose adjustment) pentazocine theophylline tricyclic antidepressants (especially imipramine and nortriyptyline).

In addition, it should be noted that through other mechanisms, there may be an increased risk of myocardial infarction when tobacco smokers take oral contraceptives.

Alcohol
Table A3.1: Interactions between alcohol and medications
Medication class
Anaesthetic agents Analgesics non-opioid Antibiotics Anticoagulants Antidepressants

Medication
Fluothane, propofol, Aspirin and NSAIDs Metronidazole and tinidazole (antabuse-type reaction), griseofulvin, quinacrine Warfarin Tricyclic antidepressants Monoamine oxidase inhibitor

Effects
Risk of liver damage; higher dosages needed to induce anaesthesia Increased risk of gastric bleeding Reduced effectiveness, nausea/vomiting, headache, seizures Increased clotting time with acute alcohol use; reduced clotting time with chronic use Increased sedation, impaired motor skills Tyramine-rich drinks (beer, red wine) may cause severe hypertension and, rarely, cardiac arrhythmias May enhance the intoxicating effects of alcohol Acute intoxication increases and chronic consumption reduces tolbutamide availability Increased sedation and dizziness, especially in elderly Enhanced side-effects, especially sedation, hypotension, impaired judgment and motor incoordination; possible increase in akathisia and dystonic reactions (small case series) Increased phenytoin levels with acute alcohol consumption May increase alcohol levels Possible increased postural hypotension Increased motor incoordination; lithium may slightly reduce intoxicating effects of alcohol in some Increased sedation, especially in

Antidiabetic agents Antihistamines Antipsychotics

Serotonin-specific re-uptake inhibitors (fluoxetine, citalopram, paroxitene) Tolbutamide Diphenhyramine (Benadryl)

Anticonvulsants Antiulcer drugs Cardiovascular meds Mood stabilisers

Phenytoin Ranitidine, cimetidine Nitroglycerin, reserpine, methyldopa, hydralazine, guanethidine Lithium

Valproate

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Opioids Sedatives All benzodiazepines Lorazepam

early phases of valproate treatment Increased sedation, possible respiratory depression, risk of overdose Sedation, motor incoordination Respiratory and cardiac depression (avoid in acute intoxication)

Sources: NIAAA Alcohol Alert January 1995, no. 27 PH 355 publication Alcohol-drug Interactions, University Health Service (UHS) Health Promotion Office, Rochester University, http://www.rochester.edu/uhs/healthtopics/Alcohol/interactions.html As noted, the interaction between lorazepam and alcohol may lead to possible cardiac and respiratory depression and should be avoided. Where sedation and incoordination are noted, tangata whaiora should be advised not to drive and to avoid using machinery.

Cannabis
Much of the information on cannabis interactions comes from research into the synthetic tetrahydrocannabinol (THC) analogue dronabinol. It should be noted that cannabis has a number of extra actions due to the large number of other compounds it also contains.

Table A3.2: Interactions between cannabis and medications

Other medication Amphetamines, cocaine, other sympathomimetics Atropine, scopolamine, antihistamines and other anticholinergics Amitryptyline, amoxapine, desipramine, other trycyclic antidepressants Disulfiram (antabuse) Benzodiazepines, alcohol, lithium, opioids, buspirone, antihistamines, other CNS depressants Theophylline Fluoxetine Naltrexone Note: CNS = central nervous system Effects Hypertension, tachycardia, possibly cardiotoxicity Tachycardia, drowsiness Addictive tachycardia, hypertension, drowsiness Possible hypomania (single case) Additive drowsiness and CNS depression Increased theophyline metabolism, similar to the effects of smoking tobacco. Possible hypomania (single case) Intoxication enhanced by naltrexone

Stimulants
Stimulants are drugs that are both prescribed and used illicitly. Amphetamines are metabolised by CYP2D6 and inhibitors of this enzyme such as paroxetine and fluoxetine. The concomitant use of methylphenidate (ritalin) and monoamine oxidase inhibitors is contraindicated due to the risk of hypertensive crisis. Methylphenidate may decrease the effectiveness of medications used to treat high blood pressure and may increase levels of warfarin and tricyclic antidepressants. Methamphetamine has many potential interactions. The following are the major interactions that can occur; in combination with: selegiline hypertensive crisis (contraindicated) bupropion increased risk of seizures tramadol seizures

39

SSRIs and venlafaxine potential increase in amphetamine activity, potential serotonin syndrome with some (e.g. dexamphetamine) linezolid (a new antibiotic) has monoamine oxidase inhibitor actions (contraindicated). sibutramine (reductil) contraindicated due to adrenergic and serotonergic reuptake inhibition.

Other medications with stimulant actions, especially those affecting the adrenergic system, can lead to increased blood pressure and pulse rate (e.g. chlorpheniramine, phenylephrine, dextromethorphin and brompheniramine), which are often found in cough mixtures. Antacids can increase amphetamine absorption and therefore actions.

MDMA (Ecstasy)
MDMA is potentially hepatotoxic, and liver function should be monitored when prescribing other medications that are also hepatotoxic, such as naltrexone and sodium valproate. It also releases large amounts of serotonin and is mainly metabolised by CYP2D6. There is therefore a risk of serotonergic syndrome, especially in combination with drugs like fluoxetine, citalopram, paroxetine, venlafaxine buproprion and pethidine. The most serious combinations include: ecstasy and MAOIs, including moclobemide (which has been associated with fatal interactions) ecstasy and ritonavir (fatalities have been reported).

Inhibition of metabolism via CYP2D6 inhibition can occur with: fluoxetine paroxetine buproprion methadone haloperidol quinidine ritonavir (antiviral agent).

Enhanced serotonergic effects can occur with: amphetamines St Johns Wort tramadol venlafaxine lithium clomipramine

Benzodiazepines and Other Sedatives

Benzodiazepines differ in terms of their metabolism. Most are metabolised by the CYP450 system in the liver and therefore are affected by other medications that increase or decrease the activity of that system. Medications that induce CYP450, such as St Johns Wort, carbemazepine, phenytoin and rifampicin, therefore decrease the action of these benzodiazepines. Medications that reduce the activity of CYP450, and therefore increase the effects of benzodiazepines, include oral contraceptives, antibiotics, antidepressants and antifungal agents. Benzodiazepines that are not metabolised by the CYP450 system, and therefore are not affected by these interactions, include lorazepam, oxazepam and temazepam.

Opioids

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Pethidine Pethidine has the potential to induce a serotonin syndrome when used together with other drugs including: dextromethorphan pentazocine tramadol tricyclic antidepressants selective serotonin reuptake inhibitors (SSRIs) monoamine oxidase inhibitors (MAOIs), including moclobemide.

Pethidine can increase risk of seizures in combination with the following drugs: theophylline tricyclic antidepressants fluoroquinolones (which can potentiate the seizure potential of pethidine).

Methadone The tendency for methadone to prolong the QT interval may be enhanced by other drugs that do the same. A list of these can be found at http://www.azcert.org/medical-pros/drug-lists/printable-druglist.cfm Precipitation of opioid withdrawal This can result from: buprenorphine pentazocine naltrexone naloxone tramadol.

Unpredictable Interactions These can result from combining opioids with: antiretroviral drugs benzodiazepines cannabis cyclizine interferon + ribavirin methylphenidate opioids promethazine tricyclic antidepressants. Decreased methadone effects This can result from combining methadone with: some antiretroviral drugs alcohol carbemazepine phenytoin rifampicin St Johns Wort tobacco. Urinary acidifiers Increased effects of methadone These can be induced by combining methadone with: cimetidine

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some antiviral drugs diazepam dihydroergotamine alcohol erythromycin fluconazole grapefruit moclobemide omeprazole serotonin-specific reuptake inhibitors verapamil cyclizine

(Leavitt 2005).

Morphine
Morphine may interact with monoamine oxidase inhibitors to cause serotonin syndrome.

Solvents and Volatile Substances

Solvents may sensitise the heart to adrenaline, and this has been associated with sudden cardiac death when adrenaline is co-administered. This usually only occurs in emergency medicine situations.

Other Commonly Prescribed Medications

Naltrexone Opioid antagonist, precipitates opioid withdrawal in those with physiological dependence on opioids. Otherwise o known significant drug interactions. Serotonin-specific reuptake inhibitors (SSRIs) (fluoxetine and citalopram) The use of SSRIs with monoamine oxidase inhibitors is contraindicated. SSRIs may lower the seizure threshold and should be used cautiously with other drugs that do the same. Serotonin syndrome may occur when SSRIs are used with other drugs that enhance serotonin activity, or with drugs that inhibit SSRI metabolism. Antipsychotics (risperidone, quetiapine, olanzapine, clozapine, chlorpromazine) Antipsychotics may be associated with an increased risk of seizures and cardiac arrhythmias especially in those with QT prolongation. This risk may be enhanced with other drugs that have similar effects, particularly amphetamines. Bupropion (Zyban) The use of bupropion and monoamine oxidase inhibitors is contraindicated. The metabolism of bupropion may be inhibited by paroxetine, sertraline and antiretroviral agents, increasing its blood levels. Bupropion inhibits the CYP2D6 isoenzyme and may increase blood levels of drugs metabolised by this enzyme, including most antidepressants (e.g. nortriptyline, imipramine, desipramine, paroxetine, fluoxetine, sertraline), antipsychotics (e.g. haloperidol, risperidone, thioridazine), betablockers (e.g. metoprolol) and antiarrhythmics, and antipsychotics. Bupropion can also lower the seizure threshold and should be used with other drugs that act similarly only with great caution. This is especially so in tangata whaiora with bulimia or anorexia nervosa due to possible increases in seizure risk in this population. Varenicline There are no known or predictive drug interactions of significance.

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Structuring Treatment
Recall the session structure discussed previously. 1. Enhance motivate and set agenda (5 minutes) 2. Review (10-15 minutes) o Goals o Review past week o Review symptoms and goals o Review homework tasks and treatment adherence 3a. Specific Interventions: (10-20 minutes) 3b. Specific Interventions: (10-20 minutes) Specific interventions include: Amplifiers; skills that amplify specific interventions e.g. mindfulness, MI, Distress tolerance, Sensory modulation Interventions for specific problems: CBT, withdrawal management, relapse prevention, Positive Interventions 4. Review session and reinforce Commitment Talk & Wellbeing talk (Values, Wellbeing vision, (10 minutes)

3a

3b

Reflective listening and other motivational change enhancement techniques when change talk arises, and when well-being talk is identified.

Exercise 4: Rachel Session Planning In small groups: 43

Appoint someone to feedback to the class Using the template below, enter the specific interventions you would plan for Rachel across the first 8 sessions of treatment

1. Session 1

2.

3a.

3b.

4.

Review

Session 2 Review

Session 3 Review

Session 4

Enhance Motivation

Set homework Review Review Session

Session 5

Set session agenda

Review Enhance Commitm ent and Wellbeing Talk

Session 6 Review

Session 7 Review

Session 8 Review

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Review

Action Plan
1. Before the next workshop, pick a client you are due to see. During your next session with them, identify any automatic thoughts, intermediate beliefs, core schema and cognitive distortions they have related to their key presenting problems.

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Appendices
1.The Case of Rachel 2. CIWA

Case Scenario - Rachel

Rachel is a 30-year-old European mother of a 5 year-old daughter who was referred to your service via the local Emergency Department after having taken an overdose of 15 Paracetamol tablets the previous night. Rachel stated that the overdose had been an impulsive action after drinking a bottle of wine and having an argument with her partner about finances. She stated that she was not trying to kill herself or that she was at risk of future overdose as she was very embarrassed at the outcome. She was reluctant to attend the appointment with your service, but did so under pressure from her partner who threatened to leave her unless she did something about her drinking and her moodiness. History of Presenting Problems Rachel described her mood as low but believed that this was normal for her. At times her mood is worse than usual for a few weeks with persistent sadness, lack of energy and motivation and diminished pleasure from things she usually enjoys. This occurs once every three months on average. At these times she finds life a struggle and has thoughts that she would be better off dead but has never actually developed the intent to kill herself. Problems with low mood have occurred off and on since she experienced a sexual assault (rape) at a party while severely intoxicated at the age of 18 years. Since then she has experienced frequent intrusive memories and ruminations related to the rape which has impacted on her intimate relationships, and experiences hyper-arousal much of the time though it is worse when socializing in larger groups. She denies any other significant mental health problems. Alcohol and Drug History Rachel started drinking alcohol with friends around the age of 14 years but having seen her fathers drinking did not drink regularly or to intoxication until after the sexual assault at age18 years. She started drinking to intoxication most weekend nights when socialising, and by the age of 20 years was drinking half to three quarters of a bottle of wine most evenings as well. Her alcohol use decreased when, at age 22 years she entered a relationship with the father of her daughter, and over the next few years she would drink occasionally when socializing but would have periods of several months at time without using alcohol. Her partner left her when she became pregnant and decided to keep the child.

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She stopped drinking when she became pregnant at aged 25 years and did not consume alcohol again until her daughter was a year old and she entered a new relationship with her current partner who also drinks heavily. For the past three years she has consumed a bottle of wine each night during the week, and up to three on Friday and Saturday nights if socializing. She acknowledges tolerance to alcohol and has tried to cut her drinking down in the past on several occasions without success. She also acknowledges that she gets argumentative with her partner when intoxicated on alcohol but denies other problems, and finds that it actually helps her to be calm in most situations. She has used cannabis on a daily basis since her mid teens and experiences craving, irritability and significant generalized anxiety when she goes without it for more than a few days, but find it helps her mood. Other than during her pregnancy, she has not had any significant periods of abstinence from cannabis. She has not used any other substances apart from tobacco, which she started smoking at 14. She currently smokes 50gms of tobacco a week and would like to stop, as it is very expensive. Other Relevant History Family History: Youngest of three siblings with an older sister and the eldest a brother. Her father died in a motor vehicle accident when Rachel was 22 years old. Father alcohol dependence. Paternal Grandfather alcohol dependence Brother convictions for assault and possession of cannabis, heavy cannabis user Mother social phobia, less problematic the last few years

Medical History: Nil of note No current medications Personal History: Rachel had a normal pregnancy, birth and early developmental milestones. She was an outgoing and happy toddler, over adventurous and exploratory. She attended six different primary schools due to her fathers frequent change in employment. At primary school she struggled academically with mathematics and reading but was otherwise intelligent, but frequently got into trouble for disobedience and being easily distracted. She was noted to have a short temper and be intolerant of discipline, talking back to teachers. She was sexually abused between on one occasion at the age of 5 by a friend of her fathers, and though she did not tell anyone, her older sister told their other she disliked him and their mother made sure he did not have access to the children. She was frequently truant from secondary school and noted to be irritable and argumentative when she did attend. Upon leaving school she worked in a range of waitressing, bar and sales jobs until becoming pregnant. Over the past two years she has taken several tertiary papers in social work and hopes to get a job in the future in community support. Her current relationship tends to involve frequent arguments though not violence. She has one or two friends whom she has know for ten years, but few other contacts she would consider more than acquaintances. Over the past 5 years she has had increasing contact with her mother, revolving around her daughter. Her siblings have lived in the United Kingdom for the last 7 or 8 years; she talks to her sister on skype once every few weeks, but has limited contact with her brother.

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CADS ALCOHOL WITHDRAWAL SCALE (CIWAA-R)

Please enter information or affix Patient Information Label

MRN Surname Given names D.O.B. ______________ Dr _________________

Sex _______ Ward ________

PROTOCOL FOR THE USE OF CLINICAL INSTITUTE WITHDRAWAL ASSESSMENT FOR ALCOHOL REVISED VERSION (CIWAA-R)
Alcohol Withdrawal Monitor the patient hourly for at least 4 hours using the CIWAA-R Contact the MO for assessment if: c) The alcohol score increases by least 5 points over the 4 hour period, OR d) The CIWAA-R total score reaches 10 or more

MANAGEMENT OF ALCOHOL WITHDRAWAL

The management focuses on five major problem areas: 7. 8. 9. 10. 11. 12. Progression to severe withdrawal, thus providing medication for withdrawal syndrome Risk of injury to self or others or self-destructive behaviour due to altered mental state Risk of dehydration, electrolyte and nutritional imbalances Potential for seizures Presence of concurrent illness which masks or mimics withdrawal To prevent Wernickes encephalopathy with thiamine administration

NURSING ACTIONS
Monitor the patients withdrawal status daily for usually 5-7days however may be up to 14 days Regular and frequent observations of patients temperature, pulse rate, blood pressure, respiratory and level of hydration. Monitor BAL to prevent risks of combining medication with alcohol Tailor Medication regime as needed by the client without over sedation. Assess effectiveness of medication daily and need for medical review Nurse in a low stimulus environment Slow, steady non threatening approach Reassure frequently, tell the patient the symptoms will pass Explain perceptual errors Frequent reality orientation Ensure patient safety Restore and maintain metabolic and nutritional equilibrium

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References:
NSW Detoxification Clinical Practice Guidelines NSW Health 199

Please enter information or affix Patient Information Label

ALCOHOL WITHDRAWAL ASSESSMENT

Date_________________
TIME Pulse B.P. Temp Item 1 2 3 4 5 6 7 8 9 10 score Sedation Type Dose TotalDose

MRN Surname Given names D.O.B. ______________ Dr _________________

Sex _______ Ward ________

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

WITHDRAWAL SEVERITY:

Mild <10:

Moderate 10-20:

Severe 20+

Date___________
TIME Pulse B.P. Temp Item 1 2 3 4 5 6 7 8 9 10 score Sedation Type dose TotalDose

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Y/N

Fraser Todd 2013

CLINICAL INSTITUTE WITHDRAWAL ASSESSMENT FOR ALCOHOL-REVISED VERSION (CIWAA-R) Item 1 Nausea and vomiting Item 2
2. 3. 2. 3. 5. 5. 6. 7.

Tremor
No tremor Not visible, but can be felt fingertip to fingertip Moderate, with patients arms extended

Ask do you feel sick to your stomach? Have you vomited? and observe 2. No nausea and no vomiting 3. Mild nausea with no vomiting 2. 3. 5. Intermittent nausea with dry heaves 5. 6. 7. Constant nausea, frequent dry heaves and vomiting

Observe patients arms extended and fingers spread apart.

Severe, even with arms not extended

Item 3
2. 3. 2. 3. 5. 5. 6. 7.

Paroxysmal sweats
No sweat visible Barely perceptible sweating, moist palms

Item 4

Anxiety

Beads of sweat obvious on forehead

Drenching sweats

Observe and ask, Do you feel nervous? 2. No anxiety, at ease 3. Mildly anxious 2. 3. 5. Moderately fidgety and restless 5. 6. 7. Equivalent to acute panic attack as seen in a severe delirium or acute schizophrenic reaction

Item 5
2. 3. 2. 3. 5. 5. 6. 7.

Agitation
Normal activity Somewhat more than normal

Item 6

Tactile disturbances

Moderately fidgety and restless

Paces back and forth during most of interview, or constantly thrashes about.

Ask, Have you any itching, pins and needles, burning or numbness. Do you feel bugs crawling on or under your skin? 8. None 9. Very mild itching, pins and needles, burning or numbness 10. Mild itching, pins and needles, burning or numbness 11. Moderate itching, pins and needles, burning or numbness 12. Moderately severe hallucinations 13. Severe hallucinations 14. Extremely severe hallucinations 15. Continuous hallucinations

Item 7

Auditory disturbances

Item 8

Visual disturbances

Ask Are you more aware of sounds around you? Are sounds harsh or frightening to you? Are you hearing anything disturbing or that you know is not there? Observe. 8. Not present 9. Very mild harshness or ability to frighten 10. Mild harshness or ability to frighten 11. Moderate harshness or ability to frighten 12. Moderately severe hallucinations 13. Severe hallucinations 14. Extremely severe hallucinations 15. Continuous hallucinations

Ask, Does the light appear to be too bright? Is its colour different? Does it hurt your eyes? Are you seeing anything that is disturbing you? Are you seeing things you know are not there? and observe 8. Not present 9. Very mild sensitivity 10. Mild sensitivity 11. Moderate sensitivity 12. Moderately severe hallucinations 13. Severe hallucinations 14. Extremely severe hallucinations 15. Continuous hallucinations

Item 9

Headaches, fullness in head

Item 10

Ask, Does your head feel different? Does it feel like there is a band around your head? Do not rate for dizziness or light-headedness. Otherwise rate severity. 8. Not present 9. Very mild 10. Mild 11. Moderate 12. Moderately severe 13. Severe 14. Very severe 15. Extremely severe

Orientation and clouding of consciousness

Ask, What day is this? Where are you?, Who am I? 5. Orientated and can do serial additions 6. Cannot do serial additions or is uncertain about the date 7. Disorientated for date by no more than 2 calendar days 8. Disorientated for date by more than 2 calendar days 9. Disorientated for place and/or person

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ALCOHOL WITHDRAWAL TREATMENT FOR SPECIALIST RESIDENTIAL UNIT OR HOSPITAL

SEVERITY WITHDRAWAL OF DIAZEPAM DOSAGE AND FREQUENCY

Mild withdrawal CIWAA-R <10 (old AWS = <4) Moderate withdrawal CIWAA-R = 10-20 (old AWS = 5-14)

Severe withdrawal CIWAA-R >20 (old AWS = >15)

Supportive care in the community. Observed by detox nurse once-twice daily Place on small dose diazepam regime. Detoxification nurse to assess if score indicates moderate alcohol withdrawal If alcohol withdrawal confirmed: give 10mg oral diazepam and observe more regularly, treat according to withdrawal score. Medical review after 60-80mg of diazepam given. The client will be admitted to hospital for severe withdrawal. If alcohol withdrawal confirmed: Medical officer will review and treat accordingly as per alcohol withdrawal protocol. Contraindications to diazepam: respiratory failure, significant livery impairment; possible head injury or cardiovascular accident. PRIMARY TREATMENT FOR SEVERE WITHDRAWAL CIWAA-R>20 The recommended regimen is oral loading doses of diazepam 20mg every 1-2 hours until: Symptomatic relief is obtained, or CIWAA-R score falls below 10, or The person in withdrawal becomes drowsy

ROUTINE PREVENTION OR WERNICKES ENCEPHALOPATHY Prophylactic Thiamine Treatment 100mg orally, up to three times per day for at least 1 week 100mg IV/IM for three days if severe withdrawal or Wernickes encephalopathy is suspected. Then oral doses indefinitely NB. Administer Thiamine before giving glucose, including food or sweet drinks. A carbohydrate load in the presence of thiamine deficiency risks precipitating Wernickes encephalopathy.

Age and body weight should be considered when prescribing diazepam. Lower doses may be more appropriate in slight individuals and the elderly (perhaps as little as 5mg). The maximum total dose of diazepam is generally 120mg over 24 hours, but in certain Situations this may still be insufficient to control withdrawal. Close specialist management is required for higher doses. If the maximum dose is reached, review of patients status and ensure that additional complication factors are not responsible for the CIWAA-R score.

Fraser Todd 2013

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