addiction medicine (alcohol and other substance use)

see also:

• addiction medicine - drug and alcohol service providers in Australia
• drug dependency
• ethanol/alcohol dependence
• opiate and opioid dependence
• acute pain Mx in drug dependent patients
• analgesics index
• opiates and opioids
• opiate antagonists eg naloxone (Narcan), buprenorphine, naltrexone
• metamphetamine / meth / ice
• National Drug and Alcohol Research Centre (NDARC) - drug trends bulletin

• MidWest Mental Health Services
• Western Health drug health, addiction medicine services
• management of drug dependent persons (docx)
• drug and alcohol use by employees (doc)
• Unknown Substances (including Illicit and Unidentifiable Substances) (docx)
• Acute Pain Management in the Opioid Tolerant Patient (including Pregnant Women) (doc)
• WH Drug Health Services Adolescent Community Programs (ACP):
  • offers a comprehensive range of options for young people with substance use issues.
  • 3-7 Eleanor Street Footscray, phone: 8345 6682, fax: 8345 6027
• Western Health Drug Health Services Women's Day Program House
  • aims to provide a safe and comfortable therapeutic environment to assist women to understand and make changes to a lifestyle of problematic or harmful substance use
  • 49 Nicholson Street Footscray, phone: 9689 5533 fax: 9687 2749

• The Severe Substance Dependence Treatment Act 2010 (the Act) provides for a brief period (up to 14 days) of detention and treatment of people with severe substance dependence in a treatment centre (currently St Vincent’s hospital Melbourne) where this is necessary as a matter of urgency to save the person’s life or prevent serious damage to their health.
• The Act only applies to people with the most severe substance dependence who are incapable of making decisions about their substance use and personal health, welfare and safety due primarily to their substance dependence. Detention must be the only means by which treatment can be provided and there must be no less restrictive means reasonably available to ensure the treatment.
• The purpose is to give the person access to medically-assisted withdrawal, time to recover capacity to make decisions about their substance use, and the opportunity to engage in voluntary treatment.
• It is expected that emergency department staff may identify individuals who have severe alcohol or drug dependence. In the first instance, they should seek expert advice from an alcohol and other drugs specialist, DirectLine (1800 888 236) or the Victorian Drug and Alcohol Clinical Advisory Service (1800 812 804) about whether the Act might apply.
• The Magistrates’ Court makes detention and treatment orders.
• The process to initiate an application to the Court commences with a recommendation made by a prescribed registered medical practitioner. The purpose of the recommendation is to provide evidence to the court that all the criteria for detention and treatment apply to the person. The following medical practitioners have been prescribed to make recommendations—
  • Fellows or affiliates of the Royal Australian and New Zealand College of Psychiatrists (RANZCP)—psychiatrists
  • Fellows of the Chapter of Addiction Medicine—addiction medicine specialists
  • Medical practitioners engaged by Victoria Police to provide medical care to persons in police custody—custodial medical officers.
• Detailed information about the Act and the process for making an application are available at SDTA

• pre-contemplation
  • has no intention of change and continues to use substances
• contemplation
  • ambivalence towards substance use and considering change
• determination / preparation
  • decision to change but is yet to begin
  • patients who use substances may delay seeking treatment at hospital for fear of stigma and being treated differently:
    • language matters:
      • clinicians should first ask for consent to discuss AOD issues and avoid using the following judgmental terms:
        • clean/sober/dependent/addict/junkie/alcoholic/abuse/drug user/dirty needle/had a setback / fallen off the wagon/ using again / has a drug habit / stayed clean / maintained recovery / drug seeking / manipulative / problem use / non-engaged / non-compliant / lacks insight / unmotivated
      • instead should use:
        • “I just want to check what substances you currently use so we can make sure we get your medications and treatment“
        • “Is it OK to chat about your substance use”
        • consider discussing legal substances such as alcohol to get them more comfortable
        • normalise substance use screening by saying we ask all patients this
        • ask open ended questions to ascertain which substance, how much, which route, how often, how long, last use, then repeat back to patient to clarify and ensure they understand you are listening to them
        • accept they may not want to act today and thus target harm reduction instead
        • person who uses/injects drugs / lived experience of substance use / pharmacotherapy is a treatment / no longer or currently using drugs / positive urine drug screen / needs are not being met / substance use / non-prescribed use / person with a dependence on .. / person disagrees / chooses not to / treatment has not been effective / used needles /
    • non-verbal cues are important
      • do not stand over them but be at same eye level
• action
  • actively commences making change to substance use
  • may have started withdrawal process or contacted a prescriber to help them
• maintenance
  • sustaining change over the longer term
• lapse
  • brief period of use then return to maintenance phase
• relapse
  • return to previous pattern of substance use

• harm reduction aims to reduce the harms associated with substance use when they are unable or unwilling to stop
  • strategies will vary depending upon substance person using such as:
    • provision of a contact card for DirectLine so they can contact free community AOD services (16 treatment catchments in Victoria) when they are ready for change noting that:
      • entry to non-residential withdrawal “detox” may take around 5 weeks of planning before the patient is admitted and length of stay is usually around 7 days and this may optionally be followed by either;
        • residential rehabilitation with duration of stay 3-24 months (this generally incurs a cost and wait times may be around 8 weeks)
        • day rehabilitation programs in which clients attend M-F for all sessions each day for a period of about 6 weeks
      • counselling sessions, wait times tend to be at least 2 weeks - these can be 4-10 sessions generally conducted weekly
      • non-residential withdrawal assisted by AOD nurse &/or GP may be an option for low risk withdrawals
      • addiction medicine clinics led by consultants for higher acuity clients with co-occurring medical and substance use issues and require referral from a doctor
    • recommend they do not use when alone
    • provide information on accessing sterile injecting equipment
    • take home naloxone for those using opioids
    • oral thiamine for those with alcohol dependence
    • education on harms
    • educate to not suddenly stop taking alcohol but to slowly reduce it and space it out across day and night
    • offer telephone follow up by addiction medicine services
    • initiate opioid replacement therapy and arrange community follow up
      • this requires prescription by a trained authorised prescriber (eg. methadone, buprenorphine)

• where possible, withdrawal management should always be referred to Addiction Medicine clinicians
• where this is not possible, an ED medical officer can instigate alcohol, GHB, and/or opioid withdrawal management in accordance with the hospital's procedures

• dose, frequency, intensity and duration of use
• mode of administration (ingested, smoked, injected)
• poly drug use
  • When more than one substance is used, it can increase severity and duration of intoxication.
• comorbid physical and mental state
• for alcohol:
  • previous withdrawal seizure
  • previous alcohol withdrawal delirium
  • history of Wernicke's encephalopathy
  • onset of withdrawal symptoms on waking
  • withdrawal signs before BAC is less than 0.10
  • an alcohol withdrawal scale should be instituted for patients in hospital and completed every 1-2hrs

• reducing psychological and physical distress
  • mild alcohol withdrawal results in distress which generally occurs from 12hrs to 4 days after cessation
• preventing and managing severe complications such as seizure or delirium
  • alcohol withdrawal seizures generally occur in 1st 72hrs of cessation and peak at around 24hrs and prior to other symptoms hence prophylactic loading dose benzodiazepines (eg. 20mg diazepam orally) are usually given in those at high risk even if not exhibiting symptoms although generally have tachycardia and hypertension as signs. At risk patients are generally give 20mg oral diazepam every 2hrs until 60-80mg dosage or patient is lightly sedated.
  • alcohol withdrawal delirium tremens and hallucinations are more likely to occur later, after 48hrs if withdrawal is severe
• preventing and managing severe psychiatric complications such as psychosis
  • patients with long term high alcohol use are at risk of Wernicke's encephalopathy if given dextrose/glucose, hence these patients should receive 300mg IV/IM thiamine daily dose (or even 500mg tds symptoms of WE - confusion, ataxia,vertical nystagmus,etc) first and this is given for 3 days. Oral thiamine is NOT absorbed well in these patients and is NOT a substitute.
• interrupting periods of heavy use
• providing linkages to services