Drug and Alcohol Detox

Drinking effects

I have found myself back in a drug and alcohol detox placement; an environment that I have not worked in for over two years.  It is amazing though how the range of medications, and associated physical health issues, have resurfaced from the recesses of my brain, usefully emerging to help me with my learning within the workplace.

For alcohol detox, usually over 7 days, patients withdraw using a drug called chlordiazepoxide (Librium), which is gradually reduced.  In order to reduce cravings, a drug called acamprosate (Campral) is also given during the detox, plus also during the period when the patient goes home.  For a patient who weighs less than 60 kg, a slightly lower dose of acamprosate will be given.

People who have drank heavily are usually deficient in essential vitamins, caused by a poor diet and alcohol destroying vitamin B levels.  Patients may be experiencing neuropathy in their fingers and toes – a kind of pins and needles feeling.  They may also be experiencing myopathy – a muscle weakness in their arms and legs, which might even be effecting their mobility.  Additionally, they may also be experiencing short term memory problems.  In order to replenish the body therefore, patients are usually given three Pabrinex intra-muscular injections – one injection daily for three days; although in very heavy drinkers whose health has been compromised even further, two injections over three days, making a total of six, may alternatively be given.  Pabrinex is a nourishing liquid medication of vitamin B and C.  In order to maximise the bodily effects even further, patients are also given vitamin B and thiamine tablets, and are encouraged to carry on taking these when they get home.

For heroin detox, patients withdraw using liquid methadone.  It is a gradually reducing regime over 14 to 28 days, depending upon the amount of heroin that was previously being used.  In order to help with withdrawals, a drug called lofexidine (Britlofex) is also given; but before administering, the patient’s pulse should be checked, in order to ensure that it is not less than 50.  For the common side-effect of restless, aching legs, there is a drug called Baclofen.  Additionally, a seven night prescription of Zopiclone is also usually available, in order to help with sleep problems.

For specific withdrawal symptoms there are a range of medications to provide relief: loperamide (Imodium) is for diarrhoea; metaclopromide is for sickness; chlorphenamine (Piriton) is an anti-histamine for itching; Gaviscon is for stomach acid; senna or lactulose is for constipation; and of course, there are paracetamol and ibuprofen for general aches and discomfort.

It is both interesting and very sad to hear about the life problems that have caused patients to start abusing drink or drugs.  Common triggers can be bereavement, divorce, unemployment, or depression; there may be singular causes or there may be multiple and cumulative causes.  Whatever the reasons, it is interesting to note that substance misuse could potentially happen to anyone.  Patients should never be judged; they are nice, normal people who have often had to cope with some terrible problems, and they have made a brave and honest choice to undergo detox, to admit their drink or drug problems and to ask for our help.  I am proud to be involved in helping these patients, and I wish them all success and much happiness in the future.

Fifth placement over and exam complete!

Last Friday I officially completed my fifth placement out of an eventual nine – so there are just four more to go before I qualify as a nurse. Yesterday I also sat the Year Two Semester Two exam on physiology, pathophysiology and assessment, which was three hours in length. All the hard work is hopefully starting to pay off, and the distant end of March 2016 is gradually getting nearer, and is less than half-way now.

My fifth placement with the Crisis Team (now called the Home Based Treatment Team) was exceptionally good, and I feel that I learned plenty. My prime objective was to complete a full patient assessment and all the associated paperwork – face-to-face client contact, initial assessment documentation, risk assessment and care plan. Fortunately this placement provided plenty of opportunities to practise these skills, and I had the benefit of working alongside a very experienced team, who demonstrated some very skilled interactions and interventions with clients.

It was good to support patients within their home environment, and to help prevent them from deteriorating and having to go into hospital. Naturally, this was not always possible, but on the opposite side of this process, we would often support patients upon arriving back home after being discharged from hospital. When improvement and stability was gradually achieved, it was then also possible to transfer the care of our patients back to the Community Mental Health Team.

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Alongside the placement I was able to complete four ‘spoke’ days, in order to gain extra experiences. Two days were spent with the RAID (Rapid Assessment Interface and Discharge) teams at two separate A & E departments, one day was spent at an inpatient psychiatric hospital, and another was spent with a Community Mental Health Nurse. During the latter, I was fortunate enough to experience a visit to a closed high security prison, and upon entering, was subjected to a body search and scan, the taking of my index finger prints and the removal of my shoes. It was amazing to go inside the old Victorian prison and onto the wing. If anyone can recall the old prison comedy drama called Porridge; well that is exactly what it was like inside.

prison

Other notable placement experiences included: talking to a suicidal patient over the phone, and being able to calm them down enough for me to call for an ambulance; making an adult safeguard referral; and taking part in a home visit involving an interpreter. It was a rich and rewarding placement experience with a wonderful team to assist me in my learning; I was very fortunate.

I had been building up to yesterday’s exam for the whole of my placement, and initially I was concerned that I would forget much of my university lecture content whilst working in the community, but fortunately this was not the case. The main medical conditions that we focused on were diabetes, heavy alcohol consumption, osteoarthritis, and stress, anxiety and depression. During placement I was able to meet real-life patients with all of these conditions, and I found that I was able to talk with them and advise them directly, with confidence, about many aspects of their condition. Much of my recent learning became relevant with clear practical application and knowledge based in reality. Accompanied with some evening and weekend revision, I felt well prepared for yesterday’s event.

exam room

Like all exams that I take, I wrote non-stop for the whole duration of three hours. Historically, I never finish exams early, and usually have to rush with the final question; and yesterday was no exception. Fortunately I was able to sleep well the night before, and did not let nerves affect me too much. I was panicking a little about remembering quotations and evidence sources to back up my knowledge, but most of them proved to be lodged in my brain and were utilised on the day. I do not yet know when the results are due to be released, but I am guessing that it might be in a couple of months’ time. Fingers and toes crossed – how will I bear the suspense? I will be very scared on the day that the marks are released.

mental capacity act       mental health code      mental health act manual

Hungry for yet more learning, I am now looking forward to starting the final semester of Year 2. The module is called Nursing Practice and Decision Making, and I am already acquiring some of the texts ready for some preparatory reading. There is still a small part of Semester Two remaining, and I am particularly looking forward to some specific learning regarding dementia; as this is a topic that is personally very close to my heart. Additional to my university learning, I have also secured myself a day on an Advanced Dementia student seminar next month, which I am greatly looking forward to. I have also just become a Dementia Friend too.

dementia friends

Alcohol and the Liver – Revision

liver and organs

The Liver

The liver is situated above the pancreas, stomach and duodenum, and has the gallbladder near to its central area. The liver is made up of lobules, with hexagonal cells called hepatocytes. These hepatic lobules are supplied with oxygenated blood from the heart through the hepatic artery. Deoxygenated blood goes back to the heart through the hepatic portal vein.

liver

Instead of capillaries, the liver’s circulation relies on the sinusoids or blood channels, which have kupffer cells inside. The kupffer cells eliminate worn out red blood cells and other unwanted debris. The liver has bile channels called canaliculi, which meet to form a common hepatic duct that supplies bile to the gallbladder. The alkaline bile is stored there until chyme (broken up food) enters the duodenum, and then it is used to emulsify the fats and neutralise the acid.

hepatocytes

The liver is basically a chemical processing plant…

The liver stores glycogen which can later be turned into glucose through the uptake of insulin. It does this to maintain blood glucose levels. The liver also makes glucose from fructose, galactose and amino acids. It also stores iron and copper, and vitamins A, B12, D, E and K. The liver converts the vitamin D into its active form, so it can assist calcium in being absorbed into the body.

In a high protein diet, the liver will break down the protein into carbohydrates and amino acids. Amino acids are DEAMINATED, or broken down, by the liver. 8 amino acids are acquired through a balanced diet, and the liver makes 12 more using the 8 that are available. Through this process of TRANSAMINATION – the manufacture of amino acids – 20 amino acids are accessed. As the amino acids are deaminated by the liver, nitrogenous waste is made, via ammonia, urea and urine. Ammonia is toxic, and so is changed into urea (less toxic), and then changed into urine and eliminated.

The liver also makes four proteins that circulate in the blood: globulin and albumen are plasma proteins, while prothrombin and fibrinogen are clotting proteins. The clotting factor of a person’s blood is measured using the INR (international Number Ratio).

The liver also makes cholesterol, including HDLs and LDLs. High density lipoproteins contain more protein than fat, and are good cholesterol. Low density lipoproteins contain more fat than protein, and are bad cholesterol.

The liver metabolises, or breaks down, all prescription and recreational drugs, including alcohol. It also changes the bilirubin so it can be excreted in the bile. Bilirubin is the broken down product of the haemoglobin from red blood cells.

Liver Disease

When the liver is damaged, bilirubin will accrue in the body, and the person will develop jaundice, appearing yellow in their skin and the whites of their eyes. The person’s faeces will be pale and clay-like.

jaundice

The blood will no longer clot easily, and there may be problems with excessive bleeding and bruising. The liver will swell up and cause the abdomen to be bloated. The person will lose weight, and experience nausea, vomiting and tiredness.

Blood tests can reliably diagnose problems with the liver, as enzymes will be raised if liver cells are damaged. ALP, ALT and AST will all be elevated, as will Gamma GT. The latter is more specific to alcohol liver disease, while the others may be more specific to liver diseases, such as Hepatitis A, B and C, and cancer.

liver healthy and ill

The Short Term Effects of Alcohol

Alcohol is a diuretic and can cause dehydration. Alcohol produces a false feeling of bodily warmth and may lead to hypothermia. Alcohol is also a depressant and will exacerbate any underlying anxiety and depression, thus reducing the efficacy of anti-depressant drugs. Unfortunately when depressed, many individuals use alcohol as a negative coping strategy. Alcohol increases the release of dopamine, and triggers the reward areas of the brain, thus making us feel happy and relaxed. This feeling does not last however, and if drinking continues, areas of the brain will be physically depressed, including judgement and reasoning, visual and spatial awareness, the management of emotions and memory impairment. Rash impulsive decisions may be made as a result, and some people may become verbally or physically aggressive, thus getting into trouble, such as fights.

jaundice man

Females may become sexually disinhibited, as their testosterone levels go up, and may thus place themselves in danger. Males, in contrast, tend to lose sexual drive through the reduction of testosterone, and can experience problems with erectile dysfunction.

The brain’s cerebellum will be affected and the person’s balance and gait will become unsteady. The body’s reflex reaction times will significantly slow, and so falling over and sustaining an injury becomes more of a risk.

Driving a car is definitely to be avoided, although many people over-estimate their abilities when under the influence of alcohol. The reality of course, is that their reaction times behind the wheel will be much slower, and so last minute braking is virtually impossible. Speeds and distances will be extremely hard to judge. It is always best to avoid drinking altogether when planning to drive, as just one unit of alcohol takes approximately one hour to be metabolised by the body.

drink driving

When drinking lots of alcohol, many people experience an increase in their appetite and often will order late-night takeaways. People drinking at home may be more tempted to cook something independently, and there have been many instances in which individuals have set their homes on fire, through oil in chip pans catching fire, because they had gone to sleep.

Exceeding sensible alcohol limits can be a high risk behaviour. It is best to avoid alcoholic binges, and to drink responsibly and safely, perhaps enjoying alcohol with a meal. Drinking alcohol with food reduces its absorption, as well as being pleasant and adding a sense of occasion.

food and wine

 

Alcoholic Drinks: Friend or Foe?

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The drinking of alcohol is often viewed as a normal social activity and part of everyday life. Many adults will relax and unwind with a glass or two of their favourite alcoholic beverage, either after work in the evenings, or on the weekends. It is often viewed as a small personal reward for working hard, and a pleasant way to achieve a feeling of relaxation. As along as sensible levels of consumption are observed and respected, drinking alcohol is perfectly acceptable and enjoyable.

Daily guideline amounts, as recommended by the National Health Service, are 3-4 units per day for a man and 2-3 units per day for a woman. To illustrate what this might represent, one unit is equal to: half a pint of regular beer, lager or cider; one small glass (125ml) of wine; or 1 single measure (25ml) of spirits. It must be noted however, that stronger beers and wines are going to be worth additional units; for example, a 440ml can of super strength lager is equivalent to four units, which is the maximum level for a male. To consume a bottle of wine, depending on the strength, you are looking at about 9 units.

In comparison to Public Houses, alcohol is relatively cheap to buy at the supermarket or local off-licences, and so many people now choose to drink at home instead. The generosity of drink measures, however, can easily be over-estimated at home. Domestic glassware measures may not be obvious and easy to monitor, and there is also a tendency to be a little more lavish when you know that the alcohol represents good value for money. The resulting outcome is that many people will unwittingly exceed their daily guideline units, or may even go further, and finish the bottle or the last can, just because it is not really worth leaving.

According to the Department of Health (2007), 24% of people in the UK are drinking heavily, either through regular drinking or binge drinking. As these people are not addicted to alcohol, they will probably not be concerned about their drinking levels, when actually they probably should be. Their short term risks may include loss of consciousness, accidents or injuries, or alcohol poisoning (potentially fatal); while their long term risks may include cancers, heart disease, liver disease or brain damage, such as memory loss or dementia.

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Heavy drinkers may also start to put on weight, as alcohol is very calorific. They may also start to age prematurely, as alcohol is not good for the skin, as it dehydrates the body; and alcohol will affect the quality of a person’s sleep, with them often missing out on the deep REM stages of the sleep cycle. Coupled with a smoking habit, which is often a common accompaniment to a heavy drinking habit, the effects upon health and personal appearance are going to be even worse.  

Alcohol is a depressant, and so heavy alcohol consumption is often linked to poor mental health. A depressed person who drinks will initially feel elated, but afterwards they will feel more depressed than before. To feel better again, they are likely to reach for another drink, and so the vicious cycle will negatively repeat itself. If a person is suffering with depression, it really is advisable to avoid alcoholic drinks altogether, as they are not going to aid with recovery.

It is worth knowing that one unit of alcohol will take roughly one hour to be metabolised by the body, and so after a heavy night’s drinking, many people will still be over the drink-drive limit in the morning. Driving when over the limit may cost you your licence and your job. In extreme circumstances, it may even cost your life or someone else’s.

This all seems really negative, but this is precisely why daily guideline unit recommendations were initially formulated. To enjoy alcohol safely, take note of the guideline amounts, the size of drinks and their alcohol content. It is always best to eat when drinking, or at least to eat prior to drinking. It is sensible practice to alternate alcoholic drinks with water or a soft drink, as this helps to prevent dehydration and to limit consumption.

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For further information, some good sites are:

Drink Aware, the Facts

http://www.drinkaware.co.uk

NHS Choices, Drinking and Alcohol

http://www.nhs.uk/Livewell/alcohol/Pages/Alcoholhome.aspx