Alcoholism and MMT: common patient presentations'

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Alcoholism and MMT common patient presentations.

• Judith Martin, MD
• Medical Director
• BAART Turk Street Clinic, SF
• AATOD workshop B1, 2009 New York

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Alcohol and methadone dont mix

• Adds sedation
• Alcohol interferes with tissue stores after dose
  dose wont last as long.
• Alcohol worsens hepatitis C picture.
• Erratic behavior in the clinic, fights, etc.
• High risk of dependence in our patients.

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Presentation, Intervention

• Intoxicated patient unable to concentrate, work
  in counseling, understand rules or give true
  informed consent.

• Short clear message cant dose.
• Avoid wasted counseling.
• Give handouts on alcoholism
• Set limits and discharge if no better.

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Presentation, Intervention

• Intoxicated patient belligerent and erratic
  behavior, disruptive to other patients, time
  consuming and effort consuming by staff to
  contain behavior

• Escort out of clinic
• Set behavior limit clearly.
• No readmission if no better, or only readmit if
  on disulfiram, etc.

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Presentation, Intervention

• Severely dependent patient, unable to abstain for
  several hours prior to dosing, therefore
  frequently unable to dose, may be so tolerant
  that never appears intoxicated.

• May or may not be able to absorb info.
• Evaluate by CIWA to decide if needs medical help
  for withdrawal dispensing may have witnessed
  pre-dose tremors.

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Presentation, Intervention

• Severely alcoholic patient with end stage liver
  disease, sometimes connected to hep C as well,
  misses lots of doses because of hospitalizations
  and positive tests.

• Give reinstatement instruction.
• Consider disulfiram.
• Warn against going into withdrawal may bleed.
• Find rays of hope.

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Presentation, Intervention

• Severely alcoholic patient on disulfiram as
  deterrent, may have frequent relapses, and
  relapse-prone resistance to taking the disulfiram
  which plays out at the window.

• Dispensing-counselor communication.
• Limit setting by dispensing.
• No readmission to disulfiram if severe mis-use.

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Presentation, Intervention

• Severely alcoholic patient, with patches of
  negative testing because of controlled drinking
  or abstinence, with frequent relapses.

• Relapse prevention during abstinence.
• Information about dangers of binge drinking to
  brain.
• Consider disulfiram.

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Presentation, Intervention

• Patient who intermittently drinks heavily, and
  tests positive after weekends or holidays. Does
  better with daily clinic monitoring.

• Avoid holiday or vacation take-homes. Permanent
  daily breathalyzer needed, even if negative. Ask
  to call in to counselor on holidays, or AA phone
  list.

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Presentation, Intervention

• Patient who only drinks long before dosing, and
  who is able to test negative, but who may stall
  when it comes to recovery work, and whose liver
  may continue to worsen.

• Info about liver damage, and brain effects. Watch
  for withdrawal and tremor. If smells of alcohol
  during counseling, send for breath test

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Presentation, Intervention

• Patients who are newly in trouble with alcohol,
  either because of change in home environment,
  stress, etc, Positive test is a marker that there
  is a new problem.

• Need lots of information about alcohol.
• Emphasize alcohol effects on methadone treatment.
  (relapse to heroin is a big danger here)

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Presentation Intervention

• Patients who have two glasses of wine with
  dinner or some such regular small amount of
  alcohol, but who may still get in trouble because
  they have hepatitis C

• Education about alcohol and hep C activation.
  Support to stop alcohol totally.

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Presentation, Intervention

• Patients who report drinking or getting drunk at
  parties to their counselor

• Education about dangers of binge drinking to the
  brain.
• Support in sober socializing, risk of addiction.
• Breathalyze daily for several months.

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Presentation, Intervention

• Patients who are alcoholic, successfully
  controlled on disulfiram.

• Continue random breathalyzing.
• Relapse prevention.
• Support in staying on disulfiram as long as
  needed.

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Presentation, Intervention

• Patients who are alcoholic, in recovery

• Relapse prevention.
• Support recovery work.
• Consider/offer random breath testing.

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Presentation, Intervention

• Patients who are not alcoholic and never drink.

• Education about alcohol and hep C may be enough.

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Alcoholism and MMT, summary.

• Alcoholism interferes with MMT in various ways.
• Education, supportive and motivational
  counseling, medical treatment, limit setting all
  useful, depend on presentation.
• Withholding the dose may be necessary for safety
  reasons.