A severely malnourished patient is admitted to hospital for planned surgery. He develops alcohol withdrawal delirium. He has no signs of Wernicke’s encephalopathy.
Which of the following is the best strategy for thiamine replacement in this patient?
C. Risk factors for developing Wernicke’s encephalopathy include a greater degree of malnutrition and severity of alcohol misuse. Oral thiamine hydrochloride cannot be relied on to provide adequate thiamine to patients at risk. This is because studies show that only a maximum of 4.5 mg of thiamine will be absorbed from an oral dose over 30 mg. In addition, patients with alcohol problems tend to have poor absorption. Therefore, intravenous delivery of high-potency B-complex vitamin therapy containing thiamine remains the standard of care for those patients with suspected Wernicke’s encephalopathy (500 mg of thiamine three times daily for three days), or who are at risk for Wernicke’s encephalopathy (250 mg three times daily for 3–5 days). In the outpatient setting, the administration of a course of intramuscular thiamine 200 mg for 5 days has been recommended because the absorption of thiamine is negated further by continued drinking after hospital discharge.
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Which of the following is not a risk factor for suicide in an alcohol-dependent individual?
B. Up to 40% of people with an alcohol use disorder attempt suicide at some time and 7% end their lives by committing suicide. Risk factors include being male, older than 50 years of age, living alone, being unemployed, poor social support, interpersonal losses, continued drinking, consumption of a greater amount of alcohol when drinking, a recent alcohol binge, previous alcohol treatment, a family history of alcoholism, a history of comorbid substance abuse (especially cocaine), a major depressive episode, serious medical illness, and prior suicidal behaviour. Suicidal behaviour is especially frequent in patients with comorbid alcoholism and major depression.
Lifetime prevalence rates of alcohol use disorder is highest in:
A. Alcohol use disorder co-occurs with other major mental illnesses. The Epidemiology Catchment Area Study reported a 13.8% lifetime prevalence for alcohol abuse or dependence in persons with bipolar I disorder in the US general population. Lifetime prevalence of alcohol abuse or dependence are: bipolarI, 46.2%; bipolar II, 39.2%; schizophrenia, 33.7%; panic disorder, 28.7%; unipolar depression, 16.5%. Patients with mania had an odds ratio of 6.2 (highest) for co-occurring alcohol abuse and/or dependence. Considering the degree of psychiatric comorbidity among alcohol-dependent individuals, the National Comorbidity Survey showed that the odds ratio (OR) of having co-occurring lifetime diagnosis of mania in patients with a lifetime diagnosis of alcohol dependence was higher in both men (OR = 12.03) and women (OR = 5.3).
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Psychosocial interventions available for alcohol dependence include motivational enhancement therapy (MET), cognitive behavioural therapy (CBT) and 12-step facilitation programmes (TSF).
Which of the following is NOT correct with regard to these interventions?
C. This question can be answered using results from a study called Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity). MATCH is one of the largest randomized trials to have examined psychosocial interventions for people with alcohol-related problems. The study is a multicentric study that involved randomizing over 1700 patients to MET, CBT, or TSF. This study demonstrated that four sessions of MET were as effective for treating alcohol dependence as 12 sessions of CBT or TSF therapy. The benefits from treatment persisted for up to 3 years. Clients with a higher degree of baseline anger fared better with MET than CBT or TSF.
MET was found to be more cost-effective than CBT or TSF. The Project MATCH study and smaller patient-matching studies provide support for the effectiveness of TSF programmes. Patients in Project MATCH who received outpatient TSF were most likely to abstain from alcohol during the first post-treatment year. TSF therapy led to a greater length of time before the patient’s first relapse and to a higher percentage of abstinent patients at 1- and 3-year follow-up. Patients in Project MATCH with social networks supportive of not drinking responded better to TSF than MET, and that participation in AA was a mediator of this effect. Project MATCH found that patients who were rated high in ‘meaning-seeking’ fared better with TSF than CBT and MET at 1-year follow-up.
Which of the following clients are the most suitable for using brief interventions for alcohol use?
A. Brief interventions are recommended for reduction of alcohol use for patients across age and gender who are heavy or problem drinkers and do not meet the criteria for severe alcohol dependence. Brief interventions are intended to be conducted by health professionals who usually are not involved in addiction treatment, e.g. clinicians in general medical and other primary care settings. Brief interventions may differ in intensity from a single 5-minute session of simple advice to stop drinking to multiple sessions lasting up to 60 minutes each. They generally consist of four or fewer visits. They are generally useful for the prevention of alcohol-related problems in patients who are at risk of developing them. They are not primarily used as a maintenance therapy for fully fl edged alcohol use disorders like dependence. The content of brief interventions can be remembered using the acronym FRAMES developed by Miller and Rollnick: feedback about the adverse effects of alcohol; emphasis on personal responsibility for changing the dysfunctional behaviour; advice about reducing or abstaining from the behaviour; a menu of options for further help; empathic stance towards the patient; and an emphasis on self-efficacy.
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