Inpatient treatment & care
of people withdrawing
from alcohol & other
substances
Dr Enrico Cementon
OCP Inpatient Leadership Forum June 2012
You’ll also find it at:
NWMH AOD Withdrawal Management
Guidelines intranet site
Executive summary
• 41 inpatient deaths, 29 most likely suicide
• 13 after absconding from IPU
– At least 2 OD opiates
• 2 in ED with dual diagnosis
• Management of co-morbid substance use
a key theme
– Opiates implicated in 4 deaths
– Drug-seeking a motivation for absconding
– Lack of intervention-planning for AOD
SUMITT Clinical Review Audit
Start 2001 to end 2004
• 212 patients
– 41 (19%) re-referred during 4-year
period
• 4 deaths
– All Dx psychosis & depression
– 3/4 OD multiple substances including
heroin; 4th opioid dependence
DD in 15 Recommendations
DD in 15 Recommendations
Dual Diagnosis
• Co-occurrence of mental health & substance
use disorder
• Narrowed definition in MH literature of serious
mental illness & substance use disorder
Implications of comorbidity
• Poorer prognosis
• Poor Rx compliance
• Repeated
hospitalisation
• Problems with
rehabilitation
• Suicide
e.g. Drake et al (1996)
•
•
•
•
Homelessness
Violence
Imprisonment
Early mortality
e.g. McEvoy (2000)
.Time……. …….Time…… …….Time…….. …….Time…… …….Time……..
Exclusion
Criteria
‘NOT OUR
BUSINESS!’
‘multi-agency,
Joint -ISP’
INTEGRATED
TREATMENT
Routine
SCREENING
DDx / comorbidity capability spectrum
Little
recognition of
co-occurring
disorders
1.
2.
‘1-stop shop’
INTEGRATED
TREATMENT
Routine
INTEGRATED
ASSESSMENT
3.
4.
Gary Croton
SUMITT
5.
NO WRONG
DOOR
Service
system
6.
7.
Darren Bate
8.
9.
10.
What does this “integrated”
really mean?
• Awareness that co-occurrence is frequent, nor
by chance
• Always a relationship between disorders 
affects outcomes
• Recognition that effective responses to people
with either mental illness or AOD disorders are
compatible
SAMSA’s Co-occurring Center for Excellence (2007)
SUMITT
Detection of substance use in MHS
• Frequent under-detection
• Suspect when
–
–
–
–
Frequent DNA’s
Poor Rx adherence
Mental state instability
Social/financial/legal problems
• Obtain collateral information
– Family, carer, case manager
– Ix: bloods & UDS/GCMS
Green et al (2007)
Assessment Process
Every client
Tobacco
Caffeine
If Positive
CAGE-AID
Comprehensive
Dual Diagnosis
Assessment
Clinical
Observation
If negative
Continue mental
health assessment
Integrated
Dual Diagnosis
Treatment Plan
SUMITT
Assessment – Alcohol Use
Recommended Drinking Guidelines
Guideline 1
Reducing the risk of alcohol-related harm over a lifetime.
For healthy men and women, drinking no more than two standard drinks
on any day reduces the lifetime risk of harm from alcohol-related
disease or injury
Guideline 2
Reducing the risk of injury on a single occasion of drinking*
For healthy men and women, drinking no more than four standard drinks
on a single occasion reduces the risk of alcohol-related injury arising
from the occasion.
* A single occasion of drinking refers to a sequence of drinks taken without
the blood alcohol concentration reaching zero in between.
Assessment – Alcohol Use
Recommended Drinking Guidelines
Guideline 3
Children and young people under 18 years of age.
-
-
Parents and carers should be advised that children under 15 years of age
are at the greatest risk of harm from drinking and that for this age group, not
drinking alcohol is especially important.
For young people aged 15-17 years, the safest option is to delay the
initiation of drinking for as long as possible.
Guideline 4
Pregnancy and breastfeeding
-
For women who are pregnant or planning a pregnancy, not drinking is the
safest option.
For women who are breastfeeding, not drinking is the safest option.
‘A Standard Drink’
SUD Diagnoses
• DSM-IV
– Substance Use
disorders
• Substance
Abuse
• Substance
Dependence
– SubstanceInduced
disorders
• ICD-10 (F10-19)
– Harmful use
(Fx.1)
– Substance
dependence
(Fx.2)
– SubstanceInduced
disorders follow
(Fx.3-9)
Multiple diagnoses
• List all applicable diagnoses
– both substance use & substanceinduced
• List separately if Dependence diagnoses
met for different drug classes
• Once criteria for Dependence met, can
never have diagnosis of Abuse for that
drug class
• ‘Polysubstance abuse’ does not exist!
SUMITT
Models of comorbidity treatment
• 1. Integrated
• 2. Sequential
• 3. Parallel
1. Integrated treatment
• Mental health treatments and substance abuse
treatments are brought together :
– same clinicians/support workers, or team of clinicians/support
workers
– same program
– to ensure a consistent explanation of illness/problems and a
coherent prescription for treatment rather than a contradictory
set of messages from different providers
• Developing evidence base
• Regarded as current best practice
2. Sequential treatment
• One treatment (either mental health or
substance abuse) followed by the other
treatment
• first deal with one set of problems and then the
other
• for comorbid anxiety/mood-substance use
disorders
• eg. 1° alcoholism  2 ° depression
3. Parallel treatment
• concurrent treatment of both the
psychiatric disorder(s) and substance use
disorder(s) by two separate agencies,
BUT:
– different goals eg. abstinence vs. harm min
– different methods eg. confrontation vs. clientcentredness; assertive case management vs.
personal responsibility
– exclusion of particular groups of comorbidity
– disputes over prime clinical responsibility
3. Parallel treatment
.Time……. …….Time…… …….Time…….. …….Time…… …….Time……..
Exclusion
Criteria
‘NOT OUR
BUSINESS!’
‘multi-agency,
Joint -ISP’
INTEGRATED
TREATMENT
want
to know
Routine
SCREENING
But we
about withdrawal
management !
DDx / comorbidity capability spectrum
Little
recognition of
co-occurring
disorders
1.
2.
‘1-stop shop’
INTEGRATED
TREATMENT
Routine
INTEGRATED
ASSESSMENT
3.
4.
Gary Croton
5.
NO WRONG
DOOR
Service
system
6.
7.
Darren Bate
8.
9.
10.
Inpatient integrated treatment of
dual diagnosis patients
1. Stabilisation of acute medical
conditions
2. Detoxification:
•
•
 withdrawal Sx
Prevent serious complications
•
DT’s, seizures, exacerbation of psychosis, death
3. Concurrent psychiatric Rx
Substance withdrawal
• Substance - specific
• Maladaptive behavioural change
– physiological & cognitive
• Due to cessation or reduction after
• Heavy & prolonged substance use
• S&S usu. opposite of intoxication
DSM-IV-TR (2000)
effects
“Detoxification”
• Clearing of toxins
• Management of the withdrawal
syndrome
– Prediction or early recognition crucial
→ Prevention of, or urgent intervention in,
potential medical/psychiatric emergency
Acute substance withdrawal in
psychiatric patients
• Typically unpleasant symptoms
– Physiological, Psychological, Cognitive
• Exacerbation of underlying or associated
conditions → confused clinician!
• Potentially serious medical conditions:
– Dehydration, electrolyte imbalance, cardiovascular
instability, infection
– Seizures, delirium
Goals of detoxification
1. Provide safe withdrawal → patient
drug-free
2. Provide humane treatment &
protect patient’s dignity
3. Prepare patient for ongoing
treatment of drug dependence
Pharmacological strategies in
withdrawal management
1. Suppress withdrawal with crosstolerant Rx
–
Usu. with longer-acting drug
2. Withdrawal reduction by altering
another neuropharmacological
process: “Symptomatic management”
3. Maintenance of other psychotropic Rx
What if the withdrawal does not
proceed well?
• Much individual variation
• Continuous re-assessment required
• Check withdrawal Rx dosing
– If inadequate → ↑ dose
– If adequate → consider other, non-addictive
Rx e.g. antipsychotic for agitation, anxiety
– NB. Consider drug interactions & sideeffects
• Consider possibility of acute medical problem
What medication prescribing regime is
followed?
Plan post-withdrawal management
• Engagement in detoxification
• Evidence of long term benefits &
reduced relapse rates
– Pharmacotherapy options
– Support & counselling
– Relevant information & resources
• Advise reduced tolerance → risk of OD
• Avoid maintenance benzodiazepines
Other issues in PharmacoRx
• Interactions
– Pharmacokinetic & Pharmacodynamic
– Risks:
• OD, sedation, drowsiness, impaired
coordination
– Avoid maintenance benzodiazepines
• Consider Rx specific to D&A field
– Anticraving Acamprosate, Naltrexone
– Substitutions Methadone, Buprenorphine
(Suboxone, Subutex)
– Disulfiram ‘renaissance’
Opiate Dependence
• Opioid use, especially heroin, confers particular
risks for morbidity & mortality
– Sedation, respiratory depression, OD
– Especially when combined with other drugs
e.g. alcohol, benzo’s, antidepressants,
antipsychotics
– Also general risks associated with IVDU e.g.
local infection, blood-borne virus
• Will require consultation +/- referral to local AOD
service or DACAS (Ph: 9416 3611)
SUMITT
Revisit old ideas for our IPUs?
• Breathalysers
• Needle disposal boxes
• Rapid result UDS
SUMITT
Conclusions
• Comorbidity or “dual diagnosis” as the
expectation
• Co-occurring, long-term, chronic relapsing
disorders
– Cycles of remission & relapse as part of recovery !
– Cycles not necessarily synchronized
→ Implications for interventions’ matching
• Legacy of separate MH & AOD systems
– Barriers to integrated assessment & treatment
Last messages
• Record all MH & SUD diagnoses
• Integrated treatment
– Current best practice
– Consider all presenting MH & substance use
problems as primary
– Compatibility of responses to DD
• Withdrawal management or detox is
only the start of the addiction recovery
process!
SUMITT
So let’s move onto the next step
in the change process to dual
diagnosis capability …
Integrated & treatment !
Thank you
Enrico.Cementon@mh.org.au
Resources
• Drug & Alcohol Clinical Advisory Service
(DACAS) Ph: 9416 3611
• Directline Ph: 1800 888 236
• Family drug help Ph: 1300 660 068
• Drug Health Services, Western Health
(previously DAS West) Ph: 8345 6682
• DPU Ph:1300 364 545
• Medicare Prescription Shopping Program
Ph:1800 631 181
• Reconnexion Ph: 1300 273 266
• SUMITT Ph: 8387 2202