Drug and Alcohol Dependence Management

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Core management
  • Aim for substance reduction and risk management in those not ready to stop.
  • Aim for cessation in those ready to stop but follow guidance below before stopping alcohol and benzodiazepines in heavy users.
Red Flags

Caution When Stopping the Following:

Alcohol: Sudden alcohol cessation can lead to seizures and delirium; however, if the person is willing to stop using alcohol, facilitate this.  (see section in Part 2). Prescribe Thiamine 100mg po or Vitamin B Complex daily as a minimum.

Benzodiazepines: Sudden cessation can lead to seizures and delirium. Consider gradually reducing the dose of benzodiazepine with supervised dispensing or refer for a more rapid reduction in an inpatient setting.

Opioids: Maintenance treatment (specialist prescription of replacement opioid medication) is generally more effective than detoxification.

Stopping Other Substances (e.g. Chamba)

  • Advise stopping completely and ask them if they are ready to do this.
  • Address food, housing and employment needs.
  • Assess and treat any physical or mental health comorbidity – ideally after 2-3 weeks of abstinence, as some problems will resolve with abstinence.

Psychosocial Treatment of Dependence

Psychoeducation

  • People can and do get better.
  • If the patient is not ready now, encourage the them to come back to discuss the issue further.
  • Success in reducing or stopping substance use is more likely if the decision is their own.
  • Inform patient and carers about any locally available services to support them – use the patient and carer information leaflets.

Counselling

  • Avoid causing shame - use a non-judgmental approach and try not to express surprise at any responses given.
  • Counsel patient using a problem solving technique – see psychosocial intervention section for more.
  • Explore brief interventions like motivational interviewing to help people reduce or quit – see mh GAP.

Strategies for reducing and stopping

  • Identify triggers for use and ways to avoid them.
  • Encourage the person not to keep substances at home.
  • Peer support groups e.g. Alcoholics Anonymous where available, religious organizations etc.

Medication and Referral

Alcohol dependence

  • Thiamine 100mg orally daily
  • Determine the appropriate setting to cease alcohol use, and arrange inpatient detoxification, if necessary and possible.

Follow-Up

  • If person not yet ready to quit or reduce, agree with them when they want to be seen again.
  • If ready to quit or reduce, review weekly.
  • If newly abstinent, review every two weeks.
  • Once abstinence established, review less frequently.