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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5536_Библиотеки_им_академика_М_И_Перельмана.pdf
Alcohol
alcohol withdrawal syndrome is also not limited to complete abstinence. A person
may suffer from this condition when she attempts or is forced to reduce the amount
she drinks.
There is not a defined point when the symptoms of alcohol withdrawal syndrome
begin. This tends to differ from one individual to another. People who have severe
addictions may find that the symptoms begin while they are still under the influence
of alcohol but have not had a drink for a few hours. Those with the most severe
addictions are also commonly the individuals who have the harshest and longest
withdrawal experiences. It is believed by many medical professionals that multiple
attempts to overcome alcohol addiction cause symptoms to become more severe
each time.
This condition may require medical treatment. In most instances, it is not necessary
for sufferers to be hospitalized but some of the more severe cases may require inpatient treatment. It may be necessary for prescription medications to be administered
for either in-patient or out-patient treatment. The American Academy of Family
Physicians says that alcohol withdrawal treatment should be followed by treatment
for alcohol dependence.
139
General Guidelines for Alcohol Withdrawal Management
Withdrawal management is just one aspect of managing alcohol dependence and
should never be considered ‘the cure’. Changing established behaviours takes
time; relapse is common. Well planned interventions and engagement in activities
supporting behaviour change will assist long-term recovery.
Depending on drinking history, medical risk and level of social support, alcohol
withdrawal can be effectively managed in a home or inpatient setting. To establish
a withdrawal management plan:
1. Assess current consumption levels
■ undertake AOD, medical, social history and mental health assessment
2. Predict likelihood and severity of withdrawal
Withdrawal is likely where:
■ there is an alcohol-related reason for admission/assessment
■ there is regular alcohol use of > 80 grams per day (males), > 60 grams
per day (females)
■ patient > 30 years (significant alcohol withdrawal is unlikely under the
age of 30)
■ < 10 days after last drink (withdrawal usually commences within 6–24
hours of last drink, and may last 2–12 days)
140
Illustrated Handbook of Drugs & Alcohol Related Health Issues
■ there is a history of alcohol dependence/ significant previous withdrawal
history
■ AUDIT Score > 12
■ other depressant/sedative medications are currently used
■ pathology results are unusual e.g. raised serum GGT or MCV
■ there is presence of alcohol-related disease (e.g. alcohol-related liver or
cardiac disease, pancreatitis, hepatomegaly)
■ physical appearance is suggestive of harmful alcohol use (parotid swelling,
abnormal skin vascularisation, conjunctival injection)
■ there is serious intercurrent illness e.g. head injury, diabetes, epilepsy,
psychosis, infection, poor nutrition, head injury, significant liver disease,
pancreatitis, cardiac or respiratory disorders.
The severity of alcohol withdrawal can be predicted by:
■ previous withdrawal history (past history of seizures, hallucinations, delirium)
■ duration and amount of alcohol used (quantity > 150g per day predictive
of severe withdrawal)
■ presence of other illness or injury increases severity and likelihood of
complications
■ use of other psychotropic drugs may result in additive or synergistic effects
The progress of the alcohol withdrawal syndrome can be seen in Figure.
Progress of alcohol withdrawal syndrome
Citation: http://www.health.gov.au/internet/main/publishing.nsf/content/E5203E6D5CBAA69
6CA257BF0001E02ED/$File/aodgp.pdf
Alcohol
141
Home Withdrawal Management
Home withdrawal may be suitable where:
■ GP is able and willing to provide home monitoring
■ carer support is available at home
■ the patient has organised responsibilities and commitments (e.g. work)
■ the patient’s physical and emotional condition is appropriate for home
withdrawal
Ensure the patient and carer are actively involved in developing the treatment plan
and are aware of:
■ withdrawal commencement date
■ possible symptoms and has discussed expectations of withdrawal process
■ medication regimes
■ support and emergency systems
Psychosocial and Physical Support During Alcohol Withdrawal
■ reorientate and provide reassurance
■ use simple commands, brief explanations, repetition (if required), use calm
but firm voice
■ treat symptoms e.g. headache, diarrhoea, generalised aches and pains,
nausea and vomiting etc. and monitor and observe for seizures or other
medical complications
■ encourage fluids and light meals e.g. vegemite on toast
■ ensure calm, uncluttered and comfortable environment with dim lighting,
comfortable clothing and clean bedclothes
Citation: https://expertbeacon.com/sites/default/files/advice_on_how_to_recover_from_a_
drug_or_alcohol_addiction_relapse.jpg
142
Illustrated Handbook of Drugs & Alcohol Related Health Issues
Delirium Tremens (the ‘DTs’)
Delirium tremens is a medical emergency associated with untreated alcohol
withdrawal, occurring 3–14 days after stopping drinking. It occurs in < 5% of
patients and may be fatal. Main features of the DTs include agitation, restlessness,
gross tremor, disorientation, fluid and electrolyte imbalance, sweating and high
fevers, visual hallucinations and paranoia.
Observation and ongoing assessment alcohol withdrawal observation
charts
Withdrawal charts provide a guide to the severity of withdrawal symptoms and use
of pharmacotherapy, but are not diagnostic instruments in themselves.
Pharmacological Management of Alcohol Withdrawal
Medications (including benzodiazepines), combined with supportive care can assist
in reducing severity of withdrawal symptoms in the home and inpatient environment.
Table 5: Medications commonly used for withdrawal management
Diazepam
Diazepam is a prescription medication primarily given to patients with anxiety
disorders, though it can also be effective at treating seizures, muscle spasms, and
symptoms of acute alcohol withdrawal. It is classified as a benzodiazepine and
works by increasing the activity of a nervous system, regulating chemicals in the
brain. The drug is familiarly identified by its principle brand name, Valium®, though
generic forms are also available. Diazepam can be habit forming and is dangerous
in large doses, so doctors are careful when prescribing the medication.
Alcohol
Gamma-aminobutyric acid (GABA) is a neurotransmitter that is released in the brain
to stabilize electrical and chemical activity of the central nervous system (CNS).
People who have anxiety disorders, tremors, seizures, and other abnormal CNS
symptoms often have too little GABA in circulation. Diazepam is a GABA enhancer;
it promotes the release of more GABA and prevents it from being reabsorbed quickly.
With increased GABA levels, CNS activity returns to normal.
143
Citation: http://images.wisegeek.com/benzodiazepine-drops.jpg
Diazepam usually comes in extended-release capsules or liquid form. Occasionally,
a hospitalized patient may receive an intravenous dose of the drug. Dosing amounts
depend on the age and condition of a patient, but most adults are instructed to
take 10 milligrams of diazepam two to four times a day. The most common side
effects are drowsiness and dizziness, though a person may also experience mental
confusion, vision changes, nausea, and loss of appetite. Allergic reactions, seizures,
and heart palpitations are rare but possible, and should be assessed in the emergency
room as soon as possible.
A doctor usually reviews a patient’s medical history and current regimen of medications
carefully before prescribing diazepam. The physician checks for possible adverse
drug interactions and starts a patient on a low dose to monitor side effects. Patients
are instructed to abstain from alcohol when taking the medication to prevent
severe health complications. In addition, a patient may be told to avoid operating
automobiles, working around machinery, or engaging in other potentially hazardous
activities due to the sedative properties of the drug.
Diazepam has the potential to become addictive. A person can become physically
and psychologically dependent on the drug, believing that he or she needs to increase
dosing amounts and frequencies to achieve the desired effects. Doctors typically
meet with patients regularly to make sure they do not show signs of addiction.
Diazepam is also a popular yet very dangerous recreational drug. The medication
can lead to severe side effects or even death when it is taken by a person who does
144
not have a prescription. Benzodiazepines (most commonly diazepam, or oxazepam
in the case of impaired liver function) are the drugs of choice in managing alcohol
withdrawal, as they:
■ alleviate many withdrawal symptoms
■ are effective in preventing development of complex withdrawal features
when given early
■ have a wide margin of safety, provided supervision is adequate
■ have low likelihood of cross-dependence, when established regimes for
withdrawal management are used
If essential prerequisites for home withdrawal management have been met, home
withdrawal using benzodiazepines may be appropriate
Illustrated Handbook of Drugs & Alcohol Related Health Issues
Citation: http://images.wisegeek.com/woman-with-insomnia.jpg
Benzodiazepines for withdrawal management in inpatient/hospital setting
An inpatient setting is more appropriate if severe withdrawal or seizures are likely,
or for those who are older, polydrug users, or physically or psychologically unwell.
The Alcohol Withdrawal Observation Chart provides a diazepam regime for inpatient
settings.
Diazepam Withdrawal
Diazepam is a tranquilizer, or central nervous system depressant, classified as a
benzodiazepine. It is used to treat anxiety, insomnia, and certain types of muscle
Alcohol
spasms. This drug can cause tolerance as well as physical and psychological
dependence, so it should not be discontinued suddenly. The abrupt cessation can
produce unpleasant symptoms of diazepam withdrawal, some of which can be
very serious. For this reason, the dose of diazepam should be slowly and gradually
reduced under the supervision of a doctor.
When patients suddenly stop taking diazepam, they may experience dizziness,
changes in personality, and numbness or tingling. Gastrointestinal symptoms, such as
nausea, vomiting, or diarrhea, might also occur. Dangerous symptoms of diazepam
withdrawal include rapid heartbeat, hallucinations, and seizures. Due to the potential
for these dangerous effects, patients should not change the dose of their medicine
without checking with their doctor. If the dose is reduced slowly, the withdrawal
symptoms will be lessened.
Diazepam withdrawal after a long duration of use is difficult. It is available in small
quantity doses of 2 milligram (mg) tablets, which can be divided into fourths for
low incremental dose reductions. Some people prefer the liquid form of diazepam
to help them gradually wean themselves from the last few milligrams. If the patient
is on a total daily dose of 60 mg of the drug, the incremental process of weaning
can take several months.
Patients on diazepam should follow some general guidelines for use. Diazepam
should never be shared with a friend or family member, particularly if they are
predisposed toward drug abuse. Patients should monitor the number of pills in the
bottle so that they will know if a member of the household is using them. The drug
should be kept in a safe spot where visitors to the home cannot get to it. Anyone
who takes diazepam needs to be aware that it is a drug frequently abused.
145
Citation: http://americanaddictioncenters.org/wp-content/uploads/2015/10/drug-withdrawal-
timelines.png.pagespeed.ce.s-Z1eXoxgn.png
146
In order to prevent tolerance and dependence, diazepam should not be used for
a long period. As a general rule, it’s best to not take it longer than a four-month
period, unless otherwise directed by a doctor. This can prevent the problem of
diazepam withdrawal. Patients may need to undergo periodic blood and liver
function tests in order to monitor the effects of diazepam. The most important thing
to remember is not to take a dose greater than that which has been prescribed, as
an overdose might be fatal.
Illustrated Handbook of Drugs & Alcohol Related Health Issues
What Are the Side Effects of Diazepam?
Diazepam is a benzodiazepine drug that can cause muscle relaxation, and is
typically used to treat anxiety disorders and possibly seizure disorders. It also may
be used to reduce dizziness in people who suffer from conditions like Meniere’s
disease. The main side effects of diazepam are separated into benign and infrequent
but serious effects requiring immediate medical attention. Not all users of this
medication experience all of its adverse effects.
The benign side effects of diazepam are also sometimes seen as beneficial. Effects
like drowsiness or feeling tired may be desirable if it is used for sleep or to reduce
anxiety. Other effects may not be as pleasant, and some of them include: excess
drooling, slight memory impairment, impairment of motor skills or hand eye
coordination required to drive a vehicle, dry mouth, disinterest in sex, changes in
speech pronunciation or speed, drunkenness or dizziness, rash, stomach upset that
could include changes in bowel movements or vomiting, headaches, and changes
to visual acuity that blur vision. These effects are not necessarily dangerous, but
a high number of adverse effects should be mentioned to a physician, as another
medication may be more appropriate.
The serious side effects of diazepam should be noted so a person can get medical
attention right away if one or more of these occur. The drug can cause a severe
allergy reaction, which is often evidenced by difficult breathing, rash or hives, and
swelling of the lips, face, and tongue. Valium may also cause increased suicidal
thinking, hallucinations, confusion, fainting feelings, reduced or faint breathing, a
sudden onset of flu symptoms that include fever, chills and muscle aches, tremors,
involuntary muscle movement or twitches, decreased inhibitions with behavior that
creates physical, emotional or financial risk, double vision, or jaundice.
A number of medications and substances either should not be taken or may enhance
the side effects of diazepam. Most psychiatric medicines are included in this list,
though they are frequently prescribed with Valium. Other medications like antiseizure drugs and pain medications may also interact with it. Doctors should have
a complete list of patient medications prior to prescribing diazepam, and should
know about patient use of cannabis or alcohol, since both of these may have a
stronger effect when used with Valium.
Alcohol
Citation: http://images.wisegeek.com/person-bent-over-clutching-stomach.jpg
Certain conditions also contraindicate use and could increase side effects of diazepam.
People who are pregnant or nursing, or who have eye diseases like glaucoma should
avoid most of the benzodiazepines. Other conditions that could contraindicate
or limit use include breathing problems like sleep apnea or chronic obstructive
pulmonary disorder, advanced diseases of the liver, and myasthenia gravis. Longterm use may create another of the side effects of diazepam. The drug tends to
cause dependency, so people are advised to discontinue use through drug tapering.
For some people, even tapering is challenging, and they may need more support
to end medication use.
147
After-Care
Aftercare is an important step in the treatment process for addiction (or any mental
health issue, for that matter). It is the stepping stone between primary treatments
such as residential drug addiction treatment and maintenance treatments. There are
several different forms of aftercare and it is important to understand each one to
be better to plan a successful recovery.
While most of these types of aftercare for drug addiction treatment are structured,
there are some things that you can do on your own, too. It is important to create
a strategy to prevent relapse and keep it with you at all times, for example. And
carry a list of contact numbers for emergencies. Keeping a journal and a gratitude
list can help, as well.
Formal aftercare for drug addiction treatment includes:
1. Step-down residential care
The first kind of aftercare is residential aftercare. This type of treatment is often
beneficial for people with very heavy drug use little support and a social circle built
around drugs. With this form of aftercare, addicts are able to have more freedom
148
within a rehab center, which means that they may be able to go to work, have
more social visits and retain control of their schedule. The benefits of this type of
care stem from the high level of support available 24/7. However, step down care
is a bridge to more responsibilities and, while structured, includes more privileges
than residential treatments for addiction.
Illustrated Handbook of Drugs & Alcohol Related Health Issues
2. Daycare (outpatient addiction treatment)
Another form of aftercare is daycare. This allows people to access resources such
as addiction counselors, therapy groups and doctors during the day while spending
their nights and evenings with family. This type of treatment is great for people who
have a good support network but still feel they will benefit from more intensive
treatment. The up side of outpatient drug addiction aftercare is that it gives people
the maximum amount of flexibility with their schedule while still providing the
most of the benefits of a residential care facility.
3. Halfway houses
Residential stays of 6 months to a year can also benefit a recovering addict. This type
of drug addiction aftercare treatment takes place in an independent and privately
owned residence. Halfway houses are best managed when rules and guidelines
include curfew, regular drug testing, and house rules. Living in a halfway house
helps recovering drug addicts make new friends, get support, and stay in a drugfree environment before living on their own again.
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