Alcoholis The bulletin of the Medical Council on Alcohol

April 2014 Vol 35; No. 2 ISSN 1351-054 for alcohol, the authors examine how the From the editor definition of brief interventions has changed In this issue over time, influenced by a number of factors, not least developments in thinking about the 1 Editorial nature of alcohol problems. 2 Alcohol at the The 2014 March/April issue of Alcohol and Roadside, the Alcoholism is devoted entirely to the topic of Emergency alcohol-related brain damage in adolescence Department [2]. This special edition covers this crucial & the Trauma topic from every angle, including policy, Centre epidemiology, marketing, genetics, brain functioning and imaging and interventions. 4 2014 Symposium Dr Dominique Florin The common point of all the articles is Programme: authorship of the highest calibre. ‘Alcohol & Older In this issue The recent decision by the Westminster People’ Last November, Professor Robin Touquet, government to shelve the proposal for 6 Book Review on our 2013 Max Glatt lecturer, gave a Minimum Unit Pricing was a disappointment Demons - our sparkling talk which captured his decades to many in the health field. Earlier this changing attitude as an emergency room physician. His year, the British Medical Journal published to alcohol, exposure to the harm caused by alcohol in a hard-hitting article detailing the political tobacco and this setting led him to his pioneering work events behind this decision. Most striking drugs reducing alcohol related harm through the was the extensive access given to the development of alcohol health workers and alcohol industry to reach politicians and Antidepressant the use of screening and brief intervention other policy makers, whilst health voices use, following in the emergency room. This is recounted in were consistently excluded. This resulted in 3 months in his article in this issue of Alcoholis. You may a policy where science came a far second recovery from also look at the MCA website where a video to industry interests. Both the original substance of Professor Touquet giving his Max Glatt article and the resulting commentary and misuse lecture is available. discussions are well worth reading [3]. 8 2014 Student We also have a piece whose lead author, 1 McCambridge J and Cunningham JA. The early Ewen McCance, is still a medical student. In history of ideas on brief interventions for alcohol. Competition Addiction 2014; 109(4):538-547. Update a small study of patients passing through a quasi-residential rehabilitation programme, 2 Alcohol and Alcoholism 2014; 49(2). Latest ‘Alcohol & notes were examined to explore the topical 3 http://www.bmj.com/about-bmj/article-clusters/ Alcoholism’ news issue of dual diagnosis. The authors remark alcohol that conclusion of treatment for a substance Winner of the MCA 2014 Max Glatt Lecture and use disorder may be associated with a New year Quiz Symposium on Alcohol and older people: decrease in use of anti-depressants. This We are delighted that our 2014 Max Glatt is of course a small observational study but lecturer will be Dr Allan Thomson. Dr suggests a need for further research in this Thomson, a long standing member of the area. MCA and founding editor of Alcohol and Professor Virigina Berridge is a historian Alcoholism, has had a most distinguished whose career has focussed on the history of career and has really been a pioneer on The Medical Council drugs and alcohol. For those of us working the topic of Wernicke-Korsakoff Syndrome, on Alcohol in this field in the ‘here and now’, her his chosen topic for the lecture. The Max 5 St Andrews Place work provides thought -provoking insight. London, NW1 4LB Glatt lecture will be followed by the annual In a review of her latest book, ‘Demons’, MCA symposium, this year on ‘Alcohol Tel: 020 7487 4445 Iain Smith reminds us how scientific and older people’. The symposium will be Fax: 020 7935 4479 understandings of drugs and addiction are of interest to health professionals across culturally and politically mediated. the range of specialties and disciplines for [email protected] In the medical press Another historical whom improving health care for older people overview is provided in Addiction [1]. In this and reducing alcohol-related harm are www.m-c-a.org.co.uk fascinating history of brief interventions imperatives.

Registered Charity Alcoholis, the quarterley bulletin for health care professionals, is published by the Medical Council on Alcohol. Views expressed by Number 265242 contributors are not necessarily those of the MCA. We welcome any articles or comments from other parties which may be published. Alcohol at the Roadside, the Emergency Department Professor Robin Touquet and the Trauma Centre

On the 14th November 2013, Professor Robin Touqet was the recipient of the MCA’s Max Glatt memorial medal: foster this delusion. Binge drinking, Max Glatt (1912-2002; founding with resulting memory loss, is an Trustee of the MCA 1967) brought increasingly common problem.8,9 It the treatment of drinking problems lays the foundations for adult alcohol- ‘in from the cold’. He unfolded the related disease.10 positive qualities of the rejected dependent drinker, always Patients must never forget that they supporting the underdog. He are responsible for their own health: gave the dependent drinker back ‘Robin Touquet’s Health Vowels’: their dignity and self-respect. (Dr ‘A’ is for Alcohol, not in excess, Spencer Madden, 1st Max Glatt Professor Touquet receiving his medal from ‘E’ is for Exercise, a must for all, Professor Drummond (MCA chairman) Lecture 2006). I thank the multi- disciplinary MCA for 21 years of ‘I’ is for Intake, for appropriate Brief Intervention (BI), 20-30 minutes alcohol education. This education diet and to avoid recreational by an AHW, remembering that BI was implemented at St Mary’s, Inhalation (and drugs), saves lives.14 Certainly AHWs being Paddington, to improve standards of ‘O’ is for Obesity, you must embedded within the ED and giving care1, 2 prevent, educative clinical support in real time to reduce junior doctor stress I focus on the hazardous drinker, ‘U’ is for Understanding that you, - e.g. to avoid the complications of highlighting ‘Functional Forgetting’ the patient, are responsible for alcohol withdrawal15,16 - generates (a very descriptive term coined by your own health. empathy and thus further referrals, Eileen Kaner, Professor of Public So for 2014, what is new for ED staff, with resulting reduced patient re- Health, Newcastle-upon-Tyne, UK) Trauma Surgeons, Alcohol Health attendance.17 and the ‘Alcostick’ (finger-prick test Workers (AHWs) and Paramedics? for alcohol, Surescreen Diagnostics, 4. ‘Why make myself so vulnerable?’ 2014). We know alcohol misuse 1. ‘Functional Forgetting’ neatly is what the young should feel after is a very common Emergency describes the variable lapses an alcohol related incident. The Department (ED) problem,3 and of recall (amnesia) in younger ‘Teachable Moment’ of opportunistic that alcohol is the most harmful hazardous drinkers (16 to 25), BA is the penny dropping that without commonly used drug.4 The potential associated with rapid acute alcohol they would not be in the ED long-term consequences for patients intoxication. Recall for what as a consequence of fall, collapse, have been clearly delineated.5 happened the night before is hazy. head injury, assault, accident or even 8,9 Families reject in life, but litigate in It is not a dense amnesia, more worse.18 Doctors’ attitudes are key, death.6 Hence the vital importance of a hazy, fragmentary forgetfulness. 19 medical students have certain early detection for young hazardous What is very sinister are the responsibilities different from those of drinkers – say 16-25 years of age increasing number of Functional MRI other students, with higher standards - before dependency sets in when Scanning studies that suggest heavy of behaviour being expected of brain chemistry is adversely, and episodic drinking in adolescence them.20 irrevocably, altered for life. This may be followed by subtle alterations 11,12 5. The ‘Screening & Intervention importance of early detection now in brain function. At present it Program for Sensible Drinking’ needs to be reflected in coding (ICD- cannot be answered how permanent, study, acronym SIPS, www.sips. 11, WHO, in preparation), so that or not, are such changes, and what iop.kcl.ac.uk/ demonstrates that hazardous drinking may be targeted their long-term implications are. effective leadership, together with for treatment.7 It must never be 2. The good news for raising AHW support, is necessary for forgotten that, ‘Every dependent standards of care is that in England implementation of an alcohol- drinker once started out as a there has been a 55% increase in misuse patient support policy. For . hazardous drinker’ the number of EDs that have direct sustainable implementation there Many young do not understand that access to Alcohol Health Workers must be a symbiosis between a 13 alcohol is a drug, rather they view (AHWs) between 2006 and 2011. senior ED clinical lead (Consultant alcohol as a ‘rite of passage’. So 3. AHWs educate ever-changing or Nursing Sister) and the AHW(s). called ‘urban regeneration’ with groups of ED doctors (as often One cannot be effective without the its greatly increased access to as every four months) and nurses other. In the USA, level I Trauma alcohol (even seducing the young about the real worth of giving Brief Centres must now screen for with ‘alcopops’), together with Advice (BA) - only 1-2 minutes of alcohol misuse, and provide BA/BI, society’s more relaxed view of feed-back - with the offer of further for certification and consequential drunkenness, have served only to funding.21 EDs may need such

Alcoholis April 2013 2 Alcohol at the Roadside, the Emergency Department and the Trauma Centre Continued... economic incentives to ensure opportunity for BACs to give 2. Patton R. Alcohol and the ED; Screening and Interventions to Reduce Harm. University similar service provision in order to immediate objective evidence, not of London; Doctor of Philosophy diploma date .22 reduce re-visits just on Resuscitation Room arrival, 31.3.11. ISBN number: 978-3-659-11753-4 but at the roadside by paramedics. 6. All questionnaires require an http://www.researchgate.net/profile/Robert_ BACs, not only provide additional Patton2/publication/ alert and orientated patient. In the clinical data for improved patient 3. Drummond D et al. National prevalence Resuscitation Room of EDs and management, but flag up those survey of alcohol related attendances at Trauma Centres - indeed at the accident and emergency departments in who, when sober having left the roadside - obtunded patients can England. Alcohol Clin Exp Res 2005; 29: 36A. Resuscitation Room, must receive give no immediate alcohol history. 4. Nutt D et al. Drug harms in the UK. Lancet BA including feed-back on their 2010; 376: 1558-65 NICE highlights that Blood Alcohol raised BAC. The Alcostick enables 5. Thomson AL et al. Managing Wernicke’s in Concentrations (BACs) compliment on-going monitoring of the BAC, the ED. Alco & Alco 2002; 37: 513-21 later use of questionnaires.23 With e.g. for the trauma patient; negative 6. Redhead J et al. Hypoglycaemia, alcohol, a Resuscitation Room BAC of more Wernicke’s & thiamine. Paragraphs 28.114-8. BACs are also important clinically.26 than 150mgs/100ml, the patient – In, Clinical Negligence. Eds. Powers M, Harris N, Barton A. 4th Edition, Tottel Publishing, even when sober - may well have In short, the Alcostick (www. 2008. little memory of what happened surescreen.com) makes BAC testing 7. Touquet R & Harris D. Alcohol Misuse Y91 to precipitate their Resuscitation universally feasible and immediate. coding in ICD-11: Rational terminology and Room delivery, including what they logical coding specifically to encourage early 9. The innovation of the Alcostick identification and advice. Alco & Alco 2012; 47: drank, for Functional Forgetting offers exciting new research 213-5. http://alcalc.oxfordjournals.org/cgi/reprint/ is associated with rapid acute ags012?ijkey=azBvPIAzIjuf8g0&keytype=ref opportunities, especially now with intoxication when BAC approaches 8. Moore S et al. The prevalence of intoxication increasingly insidious revelations 150 -200mgs/100ml. in the night-time economy. Alco & Alco 2007; 42: from Functional MRI Scanning. The 629-34. 7. The top three alcohol-related questions are:- 9. Morleo M et al. Changes in young people’s presentations to the Resuscitation alcohol consumption and related violence, A) How does Alcostick use - giving Room are Trauma, Collapse, sex and memory loss; 2009-11 North-West an immediate BAC result - affect the of England. North-West Public Health Psychiatric (‘TCP’).24 Do not delay immediacy of patient management at Observatory, December 2011. requesting BACs because patients the roadside and in the Resuscitation 10. Patton R et al. Alcohol screening and brief temporarily lack capacity; results interventions for adolescents: the how, what Room (remembering low BACs are cannot be used in court as the blood and where of reducing alcohol consumption and also clinically important)? related harm among young people. Alco & Alco has not been taken in proscribed 2014; 49: 207-12. manner by Forensic Medical Officers. B) Does increased BAC availability 11. Petit G et al. Binge drinking in adolescents: Results are confidential unless there help direct AHWs to appropriate a review of neurophysiological and is an overriding public safety interest. patients? neuroimaging research. Alco & Alco 2014; 49: 198-206. Doctors must always act in patients’ C) Does the discrepancy between 12. Wetherill RR et al. A longitudinal best interests (clinical judgement), a raised BAC and lack of patient examination of adolescent response inhibition: giving feed-back to patients when recall – the realisation of Functional neural differences before and after the initiation they are sober25 But BAC requests of heavy drinking. Psychopharmacology 2013; Forgetting - help contemplation 230: 663-71. when sent to the laboratory even as 27 of change, leading to reduced 13. Patton R & O’Hara P. Alcohol: signs of an emergency, take more than one consumption and reduced re- improvement. Emerg Med J 2013; 30: 492-5 hour to be returned. attendance? 14. Cuijpers P et al. Effects on mortality of BI for problem drinking. Addiction 2004; 99: 839-45. 8. Now in 2014, the innovation of the 15. Foy A et al. Clinical use of a shortened Alcostick: I challenge my alcohol withdrawal scale in hospital. Int Med J successors - 2006; 36: 150–4 including trauma 16. NICE. Alcohol-use disorders: Diagnosis and clinical management of alcohol related physical surgeons, nurses, complications. NICE; Clinical Guideline 100: AHWs, paramedics - www.guidance.nice.org.uk/cg100 to take forwards this 17. Crawford MJ et al. Screening and referral for brief intervention of alcohol misusing patients work; specifically to in an emergency department: a pragmatic answer the above randomised controlled trial. Lancet 2004; 364: three questions 1334-9. 18. Williams S et al. The half-life of the ‘teachable moment’ for alcohol misusing patients References:- in the emergency department. Drug Alcohol 1. Touquet R & Brown A. PAT(2009) – Revisions Depend 2005; 77: 205-8. BAC by finger-prick, result in to the PAT for Early Identification of Alcohol 19. Huntley JS et al. Attitudes towards alcohol 2 minutes, manufactured by Misuse and Brief Advice. Alco & Alco 2009; of emergency department doctors trained in the Surescreen Diagnostics (info@ 44: 284-6. Open Access. http://alcalc. detection of alcohol misuse. Ann R Coll Surg oxfordjournals.org/cgi/reprint/agp016?ijkey=HIm Engl 2004; 86: 329-33. surescreen.com) - gives the eNEO7f6izT0F&keytype=ref

Alcoholis April 2013 3 Alcohol at the Roadside, the Emergency Department and the Trauma Centre Continued...

References:- for prevention and early identification of sense in detecting alcohol intoxication in trauma alcohol use disorders in adults and young patients. Emerg Med J 2013; 30: 923-5. 20. Morgan MY & Ritson EB. Alcohol and people. NICE 2010; ScHARR Public Health Health, 5th Edition. Medical Council on Alcohol, Collaborating Centre: pages 17,107-8,118,125. 27. Rollnick S et al. Consultations about 2010. http://www.nice.org.uk/guidance/index. changing behaviour. BMJ 2005; 331: 961-3. 21. American College of Surgeons, Committee jsp?action=download&o=49007 Contact Details: on trauma. Resources for optimal care of the 24. Touquet R et al. Resuscitation Room BACs: injured patient. Chicago, Illinois: American one year cohort study. Emerg Med J 2008; Professor Robin Touquet, College of Surgeons, 2006. 25: 752-6. Open Access ent/short/25/11/75 [email protected] 22. Cherpitel CJ. Alcohol-related injury and the 2?keytype=ref&ijkey=http://emj.bmj.com/cgi/ Emeritus Professor of Emergency contObfG2ppgeG5Gwwr emergency department: research and policy Medicine, Imperial College, London; questions for the next decade. Addiction 2006; 25. Csipke E et al. Use of BACs in resuscitation and Emergency Medicine Consultant, 101: 1225–7. room patients. Emerg Med J 2007; 24: 535-8. Kingston Hospital, Surrey. 23. NICE. Screening and brief interventions 26. Malhotra S et al. The accuracy of olfactory

MCA 2014 Symposium: 19th November 2014

ALCOHOL AND OLDER PEOPLE:

The MCA 2014 symposium will focus on Alcohol and Ageing. Alcohol consumption by older people is an essential area for health policy and practice. Drinking patterns change as people get older. Whilst those over 65 drink less alcohol than their younger counterparts, they consume more frequently [1]. More older people are admitted to hospital with alcohol-related conditions than younger age groups. From 2002 to 2010 the number of alcohol related admissions in those over 65 in England doubled to reach 500,000 [2]. The trend in admissions for mental health and behavioral problems related to alcohol is even more striking, showing a 150% increase from 2002 to 2012 [3]. Alcohol related deaths in the UK in those over 75 increased by 58% between 1991 to 2001 [2]. There are particular psychosocial factors contributing to higher rates of alcohol use in this age group and many reasons why alcohol has a more detrimental effect, including co-morbidities, physical changes and drug interactions [4]. This symposium will focus on these issues across the board – from epidemiology to physical and psychiatric aspects to effective treatment. It will be of interest to health professionals across the range of specialties and disciplines for whom improving health care for older people and reducing alcohol-related harm are imperatives. 1 Alcohol and older people; Older people’s drinking habits, Institute of Alcohol Studies, 2013. Supported by unrestricted grants from: 2 Alcohol and older people; Health impacts: Hospital admissions, Institute of Alcohol Studies, 2013. 3 Trends in alcohol related admissions for older people with and the mental health problems: 2002 to 2012, Alcohol Concern 2012. 4 Our Invisible Addicts, Royal College of Psychiatrists, London 2011.

HOW TO BOOK: To book your place, send a cheque made payable to ‘The Medical Council on Alcohol’ to MCA, 5 St Andrews Place, London, NW1 4LB or contact Sapphire Ellison directly on 020 7487 4445 or Sapphire.Ellison@m- c-a.org.uk You can also book directly online at http://www.m-c-a.org.uk/calendar/ Prices are: *MCA Member Symposium attendance £45 *MCA Member Student\Retired Symposium attendance £25 *MCA Regional Advisors attendance Free For non MCA members fees range from £40 (retired/students) to £90 (other healthcare professionals). There is a 10% discount on all bookings made before 1st July 2014

Alcoholis April 2013 4

MCA Annual Meeting & Symposium: ALCOHOL & OLDER PEOPLE Programme 19th November 2014, BMA House, Tavistock Square, London WC1H 9JP

09.00 Registration & Coffee (MCA Members) 09.30 Annual General Meeting Commences (MCA members only) 10.00 MCA Legacy Essay Competition & NAAD Competition - Winners Presentation 10.10 Annual General Meeting Close

*10.00 – 10.30 Registration & Coffee (Non MCA Members)

10.15 Session Break Tea & Coffee

Max Glatt Lecture and Medal Presentation 10.35 Welcome and an Introduction to Max Glatt, Professor Colin Drummond, MCA Chairman 10.50 Dr Allan Thomson, ‘From Men to Molecules: The evolving story of the Wernicke- Korsakoff Syndrome’ 11.50 Max Glatt Memorial Medal Presentations

12.00 Session Break Lunch 13.00 REGIONAL ADVISORS MEETING (MCA REGIONAL ADVISERS ONLY)

Alcohol & Older People Seminar 13.30 Welcome and an Introduction to Alcohol & Older People, Dr Iain Smith 13.45 Dr Annie Britton (Epidemiology) 14.15 Dr Karim Dar, Consultant Addiction Psychiatrist, ‘RCPsych Report on Alcohol and the Elderly: Implications for Policy’

14.45 Session Break Tea & Coffee

15.00 Professor Simon Coulton (Brief Interventions) 15.30 Professor Ilana Crome, Professor Emeritus Keele University ‘Update on treatment effectiveness in older alcohol misusers’ 16.00 Professor Peter Crome, Professor Emeritus Keele University of Geriatric Medicine ‘Physical Effects of Alcohol in Older People’ 16.30 Closing Remarks (Q&A) 16.45 Session Close Meeting Summary and Close

All attendees will receive a delegate pack when they arrive as well as a CPD certificate. It is a great opportunity to network with collegues as well as being informative and educational. We record the AGM and the Max Glatt Memorial lecture, if you would like to view Professor Robin Touquets lecture on ‘Alcohol and the Emergency Department’, from the 2013 Symposium, then please visit our website: http://www.m-c-a.org.uk/events_1/max_glatt_memorial_lecture

Alcoholis April 2013 5

Book Review: Dr Iain Smith, Consultant Addiction Psychiatrist

Demons-Our changing attitudes to Alcohol, Tobacco and Drugs. Virginia Berridge (2013) Oxford University Press, 304pp, £16.99 ISBN-10:0199604983;ISBN-13:978-0199604982 This book by a pre-eminent British historian of alcohol and drugs is a welcome addition to a growing literature on the relevance of history to policy, practice and popular belief on mind-altering, and addictive drugs. The fact that alcohol is now seen as a drug and can be discussed alongside tobacco, heroin and cocaine among other drugs, Berridge shows us, is itself a marker of this particular historical moment. The big three drugs-tobacco, opium and alcohol- are looked at over the last two hundred years of mainly Western history in some detail. The mixed fortunes of these major players are compared and contrasted with cannabis and relative newcomers such as cocaine. (The concept of the “Columbian exchange” of both microbes and drugs between the Old World and the New I found enlightening: we got syphilis, tobacco and cocaine at our end of this trading route opened up by Columbus). With regards attitudes to alcohol one can contrast the fountain of free wine in Newcastle for the coronation of King George III with the pinnacle of the Temperance movement 150 years later. The anti-treating laws of World War I to stop strangers buying alcohol for soldiers on leave can be compared with the sending of cigarettes to those in the trenches. Opium is particularly well covered in an early chapter as are Temperance, the rise of public health including the recent concept of “risk” and the role of the professions of medicine and pharmacy in separate chapters. Berridge acknowledges the enrichment of her work brought about by a career that included early and current placements in medical institutions- the National Addiction Centre and the London School of Hygiene and Tropical Medicine respectively. She draws on and summarises her own work -e.g. Berridge and Edwards, 1981; Berridge, 2005-in a popular and accessible way. There are also eleven carefully selected illustrations. I particularly enjoyed that on page 149-an advert from the interwar years for Kensitas cigarettes-that reminded me of the spoof self-help video in the Simpsons by Troy McLure (“Smoke Yourself Thin”). This was an era when doctors endorsed cigarette brands but where alcohol was prohibited and restricted in Western societies. How things have changed since then. Berridge as a professional historian seeks understanding of the forces at play in the shaping of societal attitudes and responses to alcohol, tobacco and the ever expanding list of other psychoactive substances in as neutral a way as possible. At the same time she gives us a cogent argument for those who would take up a position in the ever shifting debates to start from a point of historical knowledge. The naivety of a proposal for the “scientific” reordering of our laws on drugs is thus brought to the fore. (An early mention is made of the 2007 Lancet article by Nutt and others). This book doesn’t attempt to predict the future in any precise way but does show us the varied paths ahead and what might determine the road eventually taken. One lesson seems to be that successful policy in this domain needs to have public opinion behind it or risk being ignored and undermined. Drug, tobacco and alcohol control policy, like politics in general, has to be the art of the possible. Virginia Berridge and Griffith Edwards (1981) Opium and the People: Opiate Use in Nineteenth-Century England Allen Lane / St Martin’s Press, 1981. Virginia Berridge, (2005) Temperance-Its history and impact on current and future alcohol policy, Joseph Rowntree Foundation.

Antidepressant Use Following 3 months in Recovery from Substance Mis- use – An initial review of notes EC McCance, MA Bruce and D McCartney

Abstract: understand the association between SUD and Psychiatric Comorbidity. Medication in all Introduction Substance Use but the Disorder (SUD) is associated with Methods A retrospective review of antipsychotic increased Psychiatric Comorbidity. notes was carried out on 96 patients Various models of relationship passing through a 3 month alcohol medication group between these conditions have and drug rehabilitation programme. showed a decrease been put forward. This study aims Changes in psychotropic medication in the number of to identify change in comorbidity were used as an indicator of change patients receiving when SUD is treated to better in psychiatric comorbidity. medication

Alcoholis April 2013 6 medication suggests Kessler’s second hypothesis or Schuckit’s model is more likely where as no change in medication suggests Kessler’s first or third model is more likely.

Method

Patient notes were obtained from those involved in the three month quasi-residential rehabilitation programme LEAP, Edinburgh and selected as follows ( Box 1.) Of those graduating from the programme (n=96) admission and discharge medication data was recorded. Antidepressant Use Following 3 months in Recovery from Substance Misuse – An initial review of notes continued.... Box 1 1280 Available records Randomly selected out - 896 Results Medication in all but the predispose to both the SUD and 384Antipsychotics, Analgesics and antipsychotic medication group other psychiatric illness OtherIncomplete Medications.). records - Medication 2 382 showed a decrease in the number 4. Sampling, reporting and namesNot and admitted doses to progr wereamme recorded. - 229 of patients receiving medication. measurement errors might 153Medication and Dose changes were Failed to graduate - 57 Of all patients on antidepressants, lead to an overestimationmedication of suggests Kessler’snoted. second hypothesis or Schuckit’s model is more likely where as no 60% remained on a constant dose, change in medication suggests96 Kessler’sNotes in first sample or third model is more likely. comorbidity. Results 23% decreased or completely Method stopped their medication. In Schuckit talks of a fifth possible Med- Forications all were groups divided except as done in the BNF under psychotropic medications(ie Antidepressants, 3 addition 10% started or increased association . In a review Patientof notes were obtainedAnxiolyticsAntidepressant from andthose Hyp involvednotics, Medication, in Antipsychotics, the three month dataAnalgesics quasi -residential and Other rehabilitation Medications.) . Medication names programme LEAP, Edinburgh and selected as follows ( Box 1.) Of those graduating from the their antidepressant dose following papers he identifies studies andwas doses not were sufficient. recorded. Medication and Dose changes were noted. that demonstrate substanceprogramme (n=96) admission and discharge medication data was recorded. a Benzodiazepine detoxification. Results- 30 patients were in the intoxication and withdrawalBox induced 1 Antidepressant group. 23% (7 Discussion Antidepressant For all groups except Antidepressant Medication, data was not sufficient. depressive symptoms. He1280 argues Available recordsout of 30) stopped or reduced medication was the only group these patients do not have a trueRandomly selected out - 896 where patients could be divided by 384 30antidepressant patients were in the Antidepressantprescriptions. group. See 23% (7 out of 30) stopped or reduced antidepressant psychiatric illness, rather secondary Incomplete prescriptions.recordsFig 1- for Seefull 2 Fig spread 1 for full ofspread results. of results. their responses. Data suggested depressive symptoms as part382 of roughly one quater of depressive Not admitted to programme - 229 the SUD which will resolve on Fig1. Antidepressant change with disorders may resolve on treatment 153 treatment. Failed to graduateconsideration -Fig1. Antidepressant 57 of Benzodiazapine change with consideration use of Benzodiazapine use of SUD. This study had multiple 96 Notes in sample The aim of this study is to explore Same Dose weaknesses requiring a larger study n=1 (3%) what proportions of patients fall in n=1,(3%) with statistical analysis to verify Medications were divided as done in the BNF under psychotropic medications(ie Antidepressants, to each of these 5 hypotheses. By n=3 (10%) these findings. Anxiolytics and Hypnotics, Antipsychotics, Analgesics and Other Medications.). MedicationDose Decrease names or using psychotropic prescriptionsand doses were as r ecorded. Medication and Dose changes were noted. Complete stop of Introduction an indicator of comorbid psychiatric Medication Substance Use Disorder (SUD) illness this study hopes toResults assess Dose Increase or start of Antidepressant following is associated with an increase how different patients respondFor all groups to except Antidepressantn= 7 (23%) Medication, data was not sufficient. Benzodiazapine n= 18 (60%) in psychiatric comorbidity the treatment of SUD. A decrease 30 patients were in in the Antidepressant group. 23% (7 out of 30) stopped or reducedDose antidepressant Increase of Antidepressant with no (Dual Diagnosis.) Regier’s psychotropic medication prescriptions.suggests See Fig 1 for full spread of results. epidemiological study showed 37% Kessler’s second hypothesis or previous Benzodiazapine Change in antidepressant of those with alcohol dependence Schuckit’s model is more likely class where as no change in medicationFig1. Antidepressant change with consideration of Benzodiazapine use 37% of those with suggests Kessler’s first or third Same Dose alcohol depend- n=1 (3%) model is more likely. n=1,(3%) ence had a current n=3 (10%) Method Only 2 of the 66 Dose Decrease or comorbid mental Complete stop of disorder Patient notes were obtained from patients not on Medication those involved in the three month antidepressants Dose Increase or start of at the Antidepressant following quasi-residential rehabilitationn= 7 (23%) Benzodiazapine had a current comorbid mental beginningn= of18 (60%) disorder whilst 53% of those with programme LEAP, Edinburgh Dose Increase of and selected as follows ( Box the programme, Antidepressant with no drug dependence (excluding previous Benzodiazapine 1.) Of those graduating from the consequently alcohol) had current comorbid needed Change in antidepressant programme (n=96) admission and class mental disorder. This compares to antidepressants. the lifetime risk of mental disorder discharge medication data was recorded. Both of these patients (excluding substance misuse) of had previously been on a 1 22.5% in the general population . Box 1: benzodiazepine reducing regime. In a review of epidemiological data, Available Records 1280 Kessler states four possibilities that Randomly Selected Out 896 are supported with some degree Running Balance 384 of evidence for the association Incomplete Records 2 Only 2 of the 66 between SUD and its comorbidity2. Running Balance 382 patients not on Not admitted to programme 229 These are: antidepressants at Running Balance 153 1. Psychiatric illness leads to Failed to graduate 57 the beginning of SUD Notes in Sample 96 the programme, consequently 2. SUD leads to other psychiatric Medications were divided as done needed illness in the BNF under psychotropic antidepressants 3. common risk factors (eg medications(ie Antidepressants, genetic or environment) Anxiolytics and Hypnotics,

Alcoholis April 2013 7 Antidepressant Use Following 3 months in Recovery from Substance Misuse – An initial review of notes continued....

Discussion Even with this in mind, it is of SUD and warrants further research relevance that 23% of patients to explore this further. This study was limited by the number did not require antidepressant of patients included. It must also Reference prescription after the substance be noted that no standardised misuse had been treated. Either 1.Regier DA et al. Comorbidity of Mental diagnostic interviews or rating Disorder with Alcohol and Other Drug these patients no longer needed scales were used to assess levels Abuse - Results from the Epidemiological antidepressants following SUD of depression. Patients that were Catchment Area(ECA) Study. JAMA treatment or antidepressants were 1990;264((19)):2511-2518. studied had been selected to the not required in the first place. Further programme as they had stable 2.Kessler RC. The Epidemiology of Dual research would be required to Diagnosis. Biol Psychiatry 2004;56:730–737 mental states and were motivated to answer this question. change. The programme provided 3.Schuckit M A. Comorbidity between changes to lifestyle, social and A small group of patients started substance use disorders and psychiatric conditions. Addiction, 2006;101((Suppl. environmental factors which would antidepressants whilst achieving 1),):76–88. also have had effects on comorbid abstinence. All of these had been 4.Olajide, D and Malcolm Lader. Depression presentations. on a benzodiazepine detoxification. following withdrawal from long-term Previous research has demonstrated 23% of patients did benzodiazepine use: a report of four cases. this regime causing depression 4,5. Psychological Medicine, (1984).;14,:937- not require antide- Clinicians should look out for this in 940. pressant prescrip- clinical practice. 5.Lader M. Anxiety or depression during tion after the sub- withdrawal of hypnotic treatments; This initial review of notes stance misuse had Journal of Psychosomatic Research shows a decrease in the use of 1994,;38,(Supplement 1,):113–123. been treated. antidepressants post treatment of

STUDENT COMPETITIONS: For more information on future competitions please check our website: http://www.m-c-a.org.uk/ medical_students/competitions or else register on the site as a non-member andto receive our e-alerts (http://www.m-c-a.org.uk/account/register/)

Latest ‘Alcohol & Alcoholism’ Journal News: It is hard to imagine a more serious and far-reaching topic than the subject of this Issue, the brains of the next generation of adults. There are chilling statistics provided here both on the drinking patterns of children of school age and on the susceptibility of their brains to this early exposure to alcohol. It is tempting to say that the young have always kicked over the traces and experimented, it was the same in our day and there is nothing new under the sun. But these aphorisms disguise a step change in the last 20 years in the number of children exposed and potentially harmed by alcohol. We also know a lot more about the development of the adolescent brain and its susceptibility to alcohol that makes inaction no longer acceptable. We have to act, and this volume is an important stimulus for that action. Read this Special Issue Roger Penwill is a cartoonist and illustrator whose work from Alcohol & Alcoholism free for a limited time. http:// has been exhibited worldwide. He has been producing www.oxfordjournals.org/page/5805/3 cartoons for the MCA since 1979

The winning answers from the New Year Quiz were: 1. B (£45 million) / 2. C (£3.6 billion) / 3. B (£2.5 million) / 4a. True / 4b. False / 4c. True Congratulations to the winner: Adam Young, a medical student from UCL

Alcoholis April 2013 8