interventions for moderate and severe alcohol dependence after successful withdrawal
Interventions based on psychological approach or social processes of change are the mainstay of therapy in people who are alcohol dependent and who have been treated for alcohol withdrawal.
- research have shown that these patients are vulnerable to relapse, and often have many unresolved co-occurring problems that predispose to relapse (for example, psychiatric comorbidity and social problems) (1)
Treatment of these patients is enhanced by both attendance at a mutual aid group and the prescribing of relapse prevention drugs.
- mutual aid groups e.g. - Alcoholics Anonymous and UK SMART Recovery
- provides ongoing support for people seeking recovery from alcohol dependence, and for partners, friends, children, and other family members
- research have shown that active participation in mutual aid results in patients achieving a sustained recovery
- clinicians should be aware of the range of mutual aid groups available locally and how to access them
- a simple three stage process to guide this is available (www.nta.nhs.uk/uploads/mutualaid-fama.pdf) (2)
- relapse prevention drugs
- acamprosate or oral naltrexone misuse.
- both drugs should be used in combination with an individual psychological intervention (cognitive behavioural therapies, behavioural therapies or social network and environment-based therapies) focused specifically on alcohol
- both drugs increase the time to first drink and to relapse in abstinence
- should be started as soon as possible after assisted withdrawal
- acamprosate or oral naltrexone in combination with behavioural couples therapy can be considered in patients who have a regular partner and whose partner is willing to participate in treatment
- disulfiram
- treatment should be started at least 24 hours after the last alcoholic drink consumed
- causes accumulation of acetaldehyde in the body and a throbbing headache, facial flushing, palpitations, dyspnoea, tachycardia, nausea, and vomiting within 10 minutes of alcohol consumption
- nalmefene
- an opioid antagonist used in patients with alcohol dependence who have a high risk drinking level (>7.5 units/day in men and >5 units/day in women), but without physical withdrawal symptoms and who do not need immediate medically assisted withdrawal.
- used only in patients who continue to have a high risk drinking level two weeks after initial assessment,
- one tablet should be taken on each day the patient perceives a risk of drinking, ideally 1-2 hours before the anticipated time of drinking (2).
Before starting treatment with acamprosate, oral naltrexone or disulfiram, conduct a comprehensive medical assessment (baseline urea and electrolytes and liver function tests including gamma glutamyl transpeptidase [GGT]). In particular, consider any contraindications or cautions (see the SPC) and discuss with the service user.
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