Historical and current practice with
regards alcohol misuse and
dependence, Opiate Replacement
Therapy and hepatitis C
Dr Iain Smith, Consultant Addiction
Psychiatrist, NHS Greater Glasgow &
Clyde Addiction Services
And Committee Member, SHAAP
The Kershaw Unit
The Most Drunken Nation on Earth?
MAJOR BURDEN OF DISEASE IN DEVELOPED COUNTRIES-RISK
FACTORS AND DISEASES
(source:The World Health report,2002)
SCOTLAND’S OUT OF STEP
Liver Cirrhosis Death Rates 1950 - 2006
Alcohol related deaths in the UK, by local
area, 1998-2004
Source: Office for National Statistics
• 15 of the 20 UK areas
with the highest male
death rates are in
Scotland
• Dundee ranks 5th
highest in the UK for
men
• For women, the
alcohol related death
rate in Dundee ranks
2nd highest in the UK
WHO GLOBAL ALCOHOL STRATEGY
2010
ACTIONS IN SCOTLAND
Public Education to mobilise support
for effective policies
Consistent messages from health ,
police and welfare organisations
Early Identification and brief advice
National programme established in
2009
Effective specialist treatment
Additional investment and national
guidance
Community action with media
advocacy
Drink driving action
Range of local “Focus on Alcohol”
projects
Effective licensing of alcohol sales
Public health principle in Licensing.
Preventing overprovision.
Regulation of marketing
Ban on multi-buy discounts and
regulation of shop displays
Price controls (cheapest alcohol)
Minimum unit price law passed.
Legal challenge from industry. At ECJ
Server training and monitoring
Now compulsory.
Consistent enforcement.
Limit reduced to 50mg Dec 2014
How Do Things Look in 2015?
Jan 06 Lancet paper
Jun 06 SHAAP set up.
May 07 Scottish Parliament
elections
Sep 07 SHAAP MUP Rpt
Apr 2009 ABI Programme
Sept 2009 Licensing Act.
(Server training, Test
purchasing,)
April 2011. Waiting Times
target
Oct 2011 Multibuy ban,
Happy hour ban, Challenge
25,
May 2012 MUP Bill Passed.
Source: ISD Scotland SMR 99
MESAS Report2014.
Quantifying the Fraction of Cirrhosis Attributable to
Alcohol Among Chronic Hepatitis C Virus Patients:
Implications for Treatment Cost-Effectiveness
Hamish A. Innes,1,2 Sharon J. Hutchinson,1,2 Stephen Barclay,3
Elaine Cadzow,3,4,5 John F. Dillon,6
Andrew Fraser,7 David J. Goldberg,2 Peter R. Mills,4 Scott A.
McDonald,1,2 Judith Morris,5
Adrian Stanley,3 and Peter Hayes8; on behalf of the Hepatitis C
Clinical Database Monitoring Committee
Innes et al-Conclusions
• A substantial proportion of patients with chronic
HCV develop liver cirrhosis as a consequence of
heavy alcohol use.
• This has not been adequately acknowledged by
cost utility analyses (CUAs). As such, estimates of
cost-effectiveness may be exaggerated.
• Thus, thesedata are important to guide
forthcoming CUAs in terms of taking better
account of the factorsleading to cirrhosis among
patients with chronic HCV. (HEPATOLOGY
2013;57:451-46
NHS GGC-OST Services
Some Challenges
• Key data on HCV epidemiology, care and disease
burden among PWID in Europe are sparse but
suggest many undiagnosed infections and poor
treatment uptake. Stronger efforts are needed to
improve data availability to guide an increase in
HCV treatment among PWID.(Weissing et
al.2014)
• There is a high prevalence of alcohol use, abuse,
and dependence in methadone maintenance
treatment (MMT) programs.
The Good Habits
 A) Screen-Ask the questions as part of the
initial assessment
 B) Intervene-Prevent or manage withdrawal
 C) Advise-Tailored brief interventions have an
effect.
 D)Refer On-Particularly in those with
dependency or recurring harmful use
Treatment-1
TREATMENT-2
• Assistance for withdrawal-home detox. ; daypatient detox.; inpatient
detox: benzodiazepines and vitamin replacement
• Psychological therapies based on motivational and cognitive models have
definite success-individual and group
• Treatment goal varies with misuse and dependence and associated
comorbidity : controlled drinking vs. abstinence; opportunistic brief
intervention
• Non –statutory agencies e.g. Alcoholics anonymous
• Pharmacotherapy- disulfiram , acamprosate, naltrexone
• Treatment of physical and psychiatric comorbidity
Potential Interactions Among Medications Used to Treat Chronic Hepatitis and
Behavioral Health Conditions
•
Prescription Medication
Indication
Potential Interaction With Hepatitis Medications
Buprenorphine
Opioid dependence
The use of boceprevir could result in an increase or decrease in buprenorphine levels. However,
the combination of buprenorphine and boceprevir has not been studied. Clinical monitoring for dose adjustment is recommended.
•
Clozapine
Schizophrenia; psychosis Clozapine might cause marrow disorders, neuroleptic malignant syndrome, and increased seizure risk. When taken
with interferon, the risks of these might increase.
•
Disulfiram Alcohol use disorders
peripheral neuropathy.
Disulfiram might cause or worsen hepatitis. When taken with interferon alpha 2a, there is increased risk of
•
Escitalopram
recommended.
The use of telaprevir can result in decreased escitalopram concentration. Clinical monitoring for dose adjustment is
•
Methadone
Opioid dependence
The use of telaprevir is associated with decreased methadone concentration. Clinical monitoring
for dose adjustment is recommended.The use of boceprevir could result in an increase or decrease in methadone levels. However, the combination of methadone
and boceprevir has not been studied. Clinical monitoring for dose adjustment is recommended.
•
Naltrexone
•
Trazodone Depression
The use of telaprevir or boceprevir can result in an increase in trazodone concentration, which might lead to adverse events (e.g.,
nausea, dizziness). The combination of telaprevir or boceprevir and trazodone should be used with caution and a lower dose of trazodone should be considered.
.
•
Depression
Opioid and alcohol use disorders
When taken with interferon alpha 2a, naltrexone might exacerbate liver damage.
Zolpidem Insomnia
The use of telaprevir can result in decreased zolpidem concentration. Clinical monitoring and dose adjustment of zolpidem is
recommended to achieve the desired response.
CONCLUSIONS
• Challenges ahead in better integrating services
for alcohol,drugs,mental health and hepatitis
C
• One stop shop model seems best where this
can be achieved with some allowance for
severity of problem and intensity of treatment
required.