Sammi: Good evening everybody and welcome to this evening’s Alcohol and Drug use in those with Anxiety, Depression or Sleep Disturbance – Practical Management Approaches. We are joined by our presenters this evening, Dr Tony Gill, Dr Murray Wright and our facilitator, Dr Merissa Cappetta. And my name is Samantha and I will be your host.
Before we jump in, I would like to make an Acknowledgement of Country. We recognise the traditional custodians of the land and sea on which we live and work, and we pay our respects to Elders past and present.
So I would like to introduce again our presenters for this evening. So we are joined by Dr Tony Gill. Tony is the Chief Addiction Medicine Specialist for the New South Wales Ministry of Health and Senior Staff Specialist in Addiction Medicine at St. Vincent’s Hospital in Sydney. He has worked in the drug and alcohol field for over 25 years. He has worked primarily as a clinician and clinical leader. In his clinical role at St. Vincent’s Hospital Sydney, he works with people with a range of alcohol and other drug problems. He works clinically in the hospital setting and the outpatient community setting. He is involved in teaching and has experience as a clinician in rural settings as well. We are also joined by our second presenter this evening, Dr Murray Wright. Murray is a graduate of the University of Sydney Medical Faculty and has worked in a range of metropolitan, rural and regional centres as a clinical and in various leadership roles, and since October 2014, as the New South Wales Chief Psychiatrist. Murray was also the Chair of the Psychiatry State Training Committee, HETI, from 2007 to 2013 and has had a number of roles with the RANZCP including membership of the quality assurance committee from 1990 to 1995, exam committee from 1996 to 2002, exemptions subcommittee from 1996 to 2005, consultation liaison working party 1992 to 1994, and New South Wales branch Rural Psychiatry Steering Group from 2002 to 2008. And finally, but certainly not least, we are joined by our facilitator this evening, Dr Marissa Cappetta. Marissa is a part-time specialist general practice in Maroubra. The other part of her time, she works as a Staff Specialist in Addiction Medicine at the Kirketon Road Centre and has been involved in the addiction medicine field since 2010. Marissa has worked in a variety of locations and settings, including Aboriginal Medical Services, Headspace, hospital in-patient units, consultation liaison, and out-patient clinics. So, thank you again, Tony, Murray and Marissa for joining us, and I will now hand over to Marissa to take us through our learning outcomes this evening.
Marissa: So, welcome everyone. So in terms of the learning outcomes, by the end of this activity, we hope that you should be able to identify if there are any problems and develop an initial treatment approach to patients presenting with symptoms such as anxiety, depression and sleep disturbance in those who may be using benzodiazepines, other drugs and alcohol. Discuss the value and processes for effective co-management with specialists in the management of complex patients. Be aware of the effective and ineffective treatments of anxiety, depression and sleep problems in the context of alcohol and other drug use. And recount the elements of an effective treatment approach for patients who present with alcohol and benzodiazepine use in the context of an array of problems including anxiety, depressive symptoms and sleep disturbance.
So we are going to be looking at how to identify when there is a problem, how we might be able to maximise the benefits of co-management with our specialist colleagues, treatment approaches that we are know are supported by evidence and what the elements of effective treatment may be.
In order to start, before I hand over to Tony and Murray, I am just going to introduce two cases that we were using as bit of background today and just to put it all into a bit of context. Just so while Murray and Tony are talking, you have the two cases in mind, because we will be referring back to them later on. So, case 1 is a 29-year-old woman who works in a call centre. She experiences anxiety with episodes of panic and sleep disturbance. She had a recent relationship breakup, presents seeking another script of quetiapine, 100 mg nocte and alprazolam 1 mg tds. You have just taken over the practice as the previous GP recently retired. You cannot find evidence of an authority for alprazolam. She tells you she will not be able to function without those medications. So just have a think about that case, and there are certainly a few things already popping up there for me.
Case 2 is a 49-year-old man who works two to three days a week. He has a gardening and mowing business. He presents to you as his GP for something to help his mood. He states he has anxiety and depression since childhood. He is already on Sertraline 50 mg in the morning which is no longer working. On further questioning, he reports sleep disturbance, early morning waking and low mood. He denies any thoughts of self-harm or thoughts of harm to others. He does get less pleasure from activities. Low energy. His appetite is fine. Weight is unchanged. No history of elevated mood or manic episodes. You find out he is drinking 120 grams of alcohol daily. He is prescribed 5 mg tds of diazepam daily, but takes extra about three days a week to sleep and when his anxiety gets bad. He tells you he smokes cannabis at night to sleep, five to ten cones, and he wants something that will work better for his mood and anxiety.
So I am going to hand over now to Tony Gill to give us a little bit of background and to talk about the addiction medicine perspective.
Tony: Thanks very much, Marissa. It is a great pleasure to be here tonight talking to you all. I mean, we chose these areas of alcohol, cannabis and benzodiazepine use in the context of anxiety and depression and sleep issues because they are obviously incredibly common and they present a range of challenges in general practice. And we not uncommonly have calls from general practitioners and work with general practitioners in the management of these problems. And one of the challenges with these patients, and there are many, but one of the challenges with these patients is to avoid over-prescribing or polypharmacy in the context of these challenging problems. And I have just got one or two slides here just to demonstrate that in fact, there are issues, there are harms associated with prescribing medications that we tend to get caught up in in the management of these problems. And you can see from the slide that is in front of you, this is data from New South Wales that shows that there is an increase in terms of looking at drug-induced deaths, there is an increasing rate of harms associated with benzodiazepines and in fact anti-psychotics like quetiapine which tend to get prescribed in the context of these patients. Obviously death is not the only harm that comes from these drugs and over-prescribing or polypharmacy in the context of these patients. But obviously it is an indication that there is continuing to be an increased rate of problems associated with polypharmacy in the management of these patients.
And when we look at this next slide, we can see that it is not a single class of drug that is causing increase in deaths, it is actually multiple classes being used together which is causing an increase in the deaths. And this is one of the issues that I think is important to bear in mind when we are trying to reduce harm and help people who have these sorts of problems.
And just by way of background, this slide also indicates again from the New South Wales data, that these deaths which are increasing are not suicide from what we can tell, but they are actually accidental drug toxicity deaths in the context of these people losing control of their medications or taking extra or getting themselves into situations where the effects or side effects of these medications are problematic. And of course there is other morbidity associated with polypharmacy and over-prescribing in the context of these very challenging patients with their very challenging problems. Our focus today is on the cases and on the very practical approaches to how you manage these patients, but just, I want to take a step back and provide a quick background around some of the fundamentals in terms of management of patients who are using alcohol, cannabis or benzodiazepines in the context of these problems.
Alcohol is obviously an issue commonly dealt with in general practice and you are very capable and commonly providing brief interventions. One of the things that probably is not done as much in general practice as I think is possible and perhaps there is a range of reasons for that, but when you do have people who are dependent on alcohol such as the person in case 2, then one of the steps to begin the approach to assisting a person, may be to help them withdrawal off alcohol. And mostly, withdrawal from alcohol can be managed in the home context, because mostly withdrawal from alcohol is an uncomplicated process. There are patients who obviously we cannot withdrawal from alcohol in the home context and they tend to be patients who have complications in withdrawal. The best indicator of whether someone is likely to have a complication in withdrawal is if they have had it before. And the two major problems that we worry about are seizures and delirium and if people have in their history that they have had those before, then obviously they are at high risk of having those again. With other patients it becomes complex in terms of managing at home in people who are using multiple drugs, multiple central nervous system depressants because that may complicated the withdrawal syndrome, and also people who have you know, serious other medical comorbidities, mental health comorbidities of a severe nature which may complicate the syndrome. And the other issue about managing people at home is of course that they do need someone around to be a support person who can assist in the process, both in monitoring and supporting them and getting them help if needed. But most of these can be predicted from history and examination in terms of determining who can be managed at home, and if someone is appropriate for home withdrawal, the process usually is prescribing diazepam in a reducing regime, starting at doses of somewhere around 10 mg four times a day, perhaps prn. Seeing people daily is the other part of managing people at home and that can be difficult in some general practice contexts, but if possible seeing them daily or at least having someone else who can see them daily, is also an important way of doing it. But many, many people can be managed in the home context who probably are not being managed there at the moment.
The other thing to say by way of background into the cases that we are talking about and the issues to do with anxiety and depression is, and you are probably aware of this, but of course alcohol itself worsens depression and worsens anxiety. And over time, just through the use of alcohol you will see that their depression can become more severe and their anxiety can also become more severe and in fact, people who present to our context, the drug and alcohol treatment context, we know that you know, often there is somewhere around about half of them or more who present with really symptoms which meet the criteria for major depression. But over about a period of four weeks, there are many of those who simply improve by not having alcohol in their system and by undertaking withdrawal to a point where that 50% can sometimes be around 5% to 10% of people who have major depressive syndrome. So, alcohol itself is something that does worsen depression and anxiety.
Cannabis, anther commonly used drug and withdrawal from it can also be managed in the general practice context. Withdrawal from cannabis is not a medically dangerous syndrome. People do not experience seizures or delirium. They tend to experience anxiety, agitation, sleep disturbance. Sometimes they eat a bit less. But the withdrawal is managed with support in the community mostly, and just low dose sometimes of diazepam 5 mg tds or qid for example, for four days only to help people get through. But the other important part of managing cannabis withdrawal in the home context is cannabis is usually used with tobacco and it is important to treat for tobacco withdrawal at the same time. We often use nicotine replacement therapy to do that. But cannabis is eminently treatable in the home context, negotiated with the patient.
It is interesting the relationship between cannabis and these questions of mental health symptoms and certainly there does seem to be some evidence that cannabis can worsen anxiety, and certainly in withdrawal it worsens anxiety. Its effect on depression is less clear.
And the other drug which again we certainly see that can be managed and in fact often is preferably managed in the community general practice context in terms of helping people to withdrawal from it, are the benzodiazepines. Withdrawal from benzodiazepines can be medically dangerous if someone has a history of seizures or people can also experience delirium in withdrawal from benzodiazepines. And they can also experience what we call misperceptions or perceptual disturbances which are like illusions of what appears like for example the wall is tilting and people can experience elevated levels of anxiety and sleep disturbance and headache when they are withdrawing from benzodiazepines. But mostly, people tend to be manageable in the home context in terms of withdrawing from benzodiazepines. Again, the important thing about doing this though, is there is regular monitoring. And the other important thing we do when we are managing people in terms of withdrawing off their benzodiazepines, is use a staged supply approach where people are only provided a small amount at any particular time and monitored regularly and reviewed regularly and there are other supports provided to deal with the symptoms which they experience in withdrawal which is usually anxiety, sleep disturbance and sometimes craving as well, and so it is important to have an approach where other people are assisting you to undertake the withdrawal but it is eminently undertakable in the community setting. Unless someone has a history of complications such as delirium or seizures. I mean, one of the issues with withdrawing people in the community can be when you have got the frail, elderly and in those contexts they can be more at risk of confusion and so we would not in that context look to withdraw them in the community, but usually other patients are amenable to that.
Benzodiazepines are interesting in terms of their impact on anxiety and depression. It is a very complex relationship, but we certainly know that there are a lot of people for example who use shorter acting benzodiazepines who experience increased anxiety towards the end of the effect of that drug, so they are sort of going in and out of anxiety and also, the relationship of benzodiazepines with depression is a complicated one. But certainly when people are using too much of it or when people are withdrawing then they can have all sorts of mood issues.
But in terms generally of drug and alcohol problems, I think the important message as well is that there are a range of treatment approaches that can be undertaken in a range of settings, but the evidence tends to tell us that there are treatment approaches which are effective and when people have chronic conditions which are related to drug and alcohol use, we know that the treatment approaches are actually as effective as the treatment of other chronic conditions. For example, when you compare chronic drug use disorders to say hypertension or diabetes or asthma, we know that the treatment outcomes are about equal for all of those conditions. And so it is not something to be nihilistic about by any means, but just to be aware of what the treatment interventions are and to try and work with others that might be available to help in terms of engaging people in treatment and supporting them through it. The primary mode of treatment for drug and alcohol conditions are psychological interventions, be it individual or group interventions, or so-called self-help interventions such as SMART recovery or AA. And we do in both patients whose response is limited to that and in other patients for other reasons, we do often combine those psychological interventions with medications and we have a range of medications there to help with drug and alcohol dependence treatment, opiate dependence treatment and certainly tobacco dependence treatment. For those people that have got the more severe disorders which are causing them more substantial problems across their life, then there are residential programs that are also known to be effective and they are more effective the longer people stay in them. And so, they are provided by non-Government organisations, private organisations and people do stay, particularly over a period of over three months and we know that they are effective as well.
So that is just a brief background to say that there are a range of drug and alcohol treatments that are available to these patients, but the issues in treating them are about engaging with the patient, or working with the patient to a point where they are of a mind to see the importance of making a change to their drug and alcohol use and seeing the importance of how their drug and alcohol use actually can impact on the symptoms which are distressing them and by reducing their drug and alcohol use the symptoms which are distressing them may in fact be reduced, such as anxiety and depression and things like sleep disturbance. I will hand over to Murray then just to provide a bit of background as well from a psychiatrist perspective.
Murray: Thanks Tony and Marissa. Look, I think that Tony said at the outset that the case histories that we have chosen and the sorts of cases that we are talking about tonight can present complex problems in a general practice setting. I think I need to say that they present complex problems in a specialist setting as well. It can be relatively simple conceptually to understand what the issues might be that are contributing to these sorts of presentations, but it is actually quite challenging to go on what is often a very long and complicated journey with the patient to get to the point where you can actually feel like you are managing the issues as you would like to according to the book. So, I think that the messages from a psychiatric perspective when you are working with these sorts of presentations is to take a long-term view. Both these cases are individuals that I could see in my practice and at least one of them resembles someone that I do see in my practice and I think that it is one thing as the clinician, to identify that you have got a problem with a blending of psychiatric and substance use problems. It is really important to move through that process of trying to bring the patient to share your perspective of what the causality is. So in both these cases, you have got the patient who is seeing the medication as a solution, whereas in our heads, we are thinking straight away that the medication is a significant part of the problem. That is actually speculative on both parts. We do not know the direction of the causality between the psychiatric symptoms and the substance use. We just know that they have got a destructive interaction.
So the principles that I think are really important are to take a very long term view and not try and solve the situation or even to persuade the patient of your perspective, definitely not in the first session or a short number of sessions. It can take weeks or months to earn sufficient trust of the patient that you are there to try and assist and be able to perhaps shift their perception which starts as medication as a solution to some of these medications as actually the cause of their problems.
So the priorities in that slide there, are firstly focus on the therapeutic alliance, because if you do not have a therapeutic alliance, then you know, the foundation of a therapeutic alliance is a shared view of what you are meeting for. In many of these situations, the patient’s reason for being in the room is actually quite different to what you would like to achieve in the medium to long term. So, trying to develop that alliance is actually a fundamental step in the process. During that process, you can also work on trying to clarify the symptoms and the diagnoses, because in almost all instances, you are looking at someone who has got a chronic relapsing condition and trying to tease out the longitudinal story of how these psychiatric symptoms fluctuate, what treatments have been trialled in the past and a very detailed assessment of what was tried and why they did not work or why they were not persevered with, is really important because part of getting that therapeutic alliance is trying not to repeat the mistakes that have occurred in previous treatment attempts and really paying attention to the patient perspective on why they did not like a particular treatment. Because we might think it is a terrific treatment, but if the patient experiences it as not positive, then we do not want to go there again. During that process of clarifying the symptoms and the diagnoses, you are also able to introduce the concept of the appropriate use of the medications and express in some cases your support for certain interventions and perhaps introduce the idea of some of the deleterious effects of the other medications as Tony has just been talking about.
I put the last dot point there as the non-pharmacological treatments and the reason for that is, that what we are talking about is people who do have complex comorbidities. They do have a substance use problem and they do have co-existing mental health issues. And so, a non-pharmacological treatment is something that you do not introduce on day 1. It is something that you start to talk about once you have achieved some level of rapport. It is highly likely that people have previously talked about non-pharmacological treatments and the patient perspective is often that they are either being condescended to or their symptoms are being minimised, or they are being judged in an adverse way. So you really want to not go to that, even though that is a fundamental part of an effective treatment of these conditions, it is something you introduce when you feel like you have got the person’s trust. And they have got some basis of shared understanding of the benefits and risks of the various different treatments that they have had.
The next slide, there we go. Just going into the therapeutic alliance. Sometimes people see this as a bit of a preliminary to treatment. But it is actually the basis is successful treatment. You could have someone turning up on a regular basis, but if you do not have a shared view of what they are doing there and what you are trying to achieve, then it is going to be a fairly unhappy experience. And so it is really important to understand the whole person. And I think there is enough in the cases that have been presented tonight to see that there is highly likely to be a back story to each of those cases, which can explain how we have ended up where they are. It is really important not only that we understand that story, but that we give the person the opportunity to describe how it is that they have got into that situation. I think that giving the opportunity for the patient to express what – I have said their feelings, idea – it should be ideas not idea, and expectations, but I think there is often a very high level of anxiety about what will happen if some of the medication that they have become dependent on, is withdrawn and so again, I think it is indicative in the cases that you have seen that we have talked about tonight, you know, you have been more or less given an ultimatum that if this is not allowed to continue, then I am not going to cope and so, trying to get behind, well why do you think that is, and taking the time to do that, I think becomes a really important part of successfully navigating this process. I should say, in my practice, when I have successfully done this with patients and it is not always successful, we are talking months to get through this process. And so you need to have some kind of interim agreement as to you know, what are you going to be doing and what are you expecting the patient to do. And you have got to be prepared to negotiate that process, particularly early on in the time that you are seeing them. And so, having some shared goals and having interim goals yourself, because the end point is likely to be something that they are not very prepared to sign up for the first couple of times they see you. It is highly likely that they have been told before that there are risks attached to the way they are self-medicating. And so they are going to be quite defensive about that. So introducing goals which are achievable as opposed to focussing on the end point which is what you desire. I think that is a really important part of engaging them. And identifying what it is you are going to bring to the exercise. What are you going to do? So in many cases there is a catastrophic thought in the back of the patient’s mind. If I do not get this medication which I have been taking for a number of years, there is going to be a catastrophe and I am not going to cope. So having some kind of a contingency plan in the event of that catastrophe which you know, in most cases we believe is not going to occur, I think is an important part of engaging people. It is really important not to be judgemental. I think sharing information in a way which is not judgmental is actually quite tricky and my experience with most people in these sorts of situations is that they are highly sensitised to being judged. It is unlikely that they are oblivious to what the general community thinks about high levels of alcohol consumption, high levels of cannabis consumption or regular use of benzodiazepines. It is in the community. So, they are on the lookout for a judgmental clinician and it is probably not augur well for the relationship. So trying to align yourself with how this person got into this situation, what where the circumstances that caused this to occur? And being empathic and non-judgemental and encouraging and optimistic, because it is very easy for people to project doom and gloom when dealing with these kinds of complex situations. And I think it is really important to be able to say you know, look we are not going to solve this in the next few weeks. We need to look at this as a project that we are embarking on together over a period of time. Those kinds of sort of framing what the alliance is, I think becomes really important in trying to work with someone on these sorts of issues.
So, next slide. Which we will get to in a second. So, I need to say that I am not driving the slides at this point. So the next slide is really just talking about things which I am sure is part of your everyday practice. But I think it is nice to have a framework as to how you are going to work through things with patients with these kinds of complex presentations. Most of my patients that I see do have a mental health issue and so if someone comes in and says, well I have got this depression or this anxiety, I think it is really important to very quickly identify that, well these are ultimately subjective experiences and so I need you to describe what your experience of depression is and what it has been, and let us spend some time trying to understand how it has affected your life off and on over the years. So trying to drill down on those labels if you like and to break into individual experiences, and also the things which make it better or worse, then over time it is really quite important to get a longitudinal picture, because most people who suffer from depression and anxiety will have had some experience, often dating back to their adolescence, or early adult years, and it fluctuates. And so trying to understand how that fluctuates and sometimes it is around life stress, sometimes it is around other things. So, it is also important to identify the things that have made it better over the years. So making an assumption that a person has always had a high level of anxiety or depression and been affected by it, is often wrong. So looking at well, what is the positive here? How did you get through that depressive episode or that anxiety? That timeline becomes helpful. It also helps you to identify the treatments that have worked and not worked and to get a sense of what are the things which this individual is likely to be able to accommodate.
I have identified there some possible contributing factors. Personality. I think in someone who is describing themselves as having either anxiety and or depression and using a lot of either alcohol or other drugs to manage that, we can completely misjudge their personality. That is often someone who is at a bit of a low point in their life and so it is quite important to try and figure out what this person’s strengths are at that point and to work out what things have contributed to their use of the medication.
The experiences of trauma and adversity. Domestic violence is a significant issue in our community still, and I think always asking about early trauma in either people’s childhood experiences or in their own relationships. If you do not ask, you will not find out. It is something that many people can be quite ashamed of and they will not volunteer that information. It can be a very, very significant player in someone who is vulnerable to either anxiety or depression.
I think the next dot point which is about assessing the relationship of the symptoms to the use of substances, this is something which is absolutely crucial in trying to figure out the causality, the direction of the causality between the medications or the drugs and the symptoms. And it can take quite a time to figure that one out.
And lastly there, I think that most people who suffer from anxiety or depression will have a diagnosis or a label that they use. It is really important not to accept those at face value. And so satisfying yourself of what were the component symptoms of either the anxiety or the depression or any other mental health issue, if possible in the absence of substance use. And critiquing the diagnosis, but also being prepared to change your opinion over time depending on how things fluctuate is really important.
Marissa: I just want to interrupt Murray for a second there. A few questions that have popped up, and most of them I am going to leave, but there is one particularly just about this. Can you explain about the role of family history when talking about this?
Murray: Yes. Look, I think that that is a good question because I think when you are talking about the chronology of the person’s symptoms, it is actually useful to know about their family background. I talked before about an experience of trauma, but obviously if someone is presenting with a history of anxiety or depression, you need to ask about family history. There is a heritability for these conditions. And it can give you some kind of a clue in someone who has got comorbid substance use. If there is a history of, for instance, major depression, again it is quite important to sort of drill down on those kinds of labels. So someone might say well look, my dad suffered from anxiety. And you say, well can you just tell us a little bit about how it affected him? Did he also suffer from alcohol misuse? Or did his anxiety cause him to miss work or leave jobs? Trying to get a sense of was it someone who was vulnerable to stress, or did they have a fully-fledged anxiety disorder becomes really important. It does help you to understand what the connection might be between the medication or substance use and their past history.
Marissa: Sure, thank you.
Tony: It is interesting also, heritability of drug and alcohol disorders or substance use disorders, and you may think about alcohol use for example and I mean obviously there is a combination of factors to do with the experience of being in a family growing up where there is dependence, but also there is a genetic component as well, which does not mean that someone is going to have a problem, it just means that they may be more at risk.
Murray: And it helps us to sort of develop a hypothesis about what are the things that are contributing to this current state? And certainly family history is not decisive, but it is very, very helpful in pushing us into a particular direction.
So, this is my last slide before we go back to the cases. And just talking about, at a certain point, and this is more of an art than a science, it becomes appropriate to begin to critique the indications for the use of the medications. And I think we have got some examples tonight which I think leave open to that. Again, one has to be really careful about appearing to be judgemental and making it sound as if someone has done the wrong thing. Even if it is an implied criticism of a treating clinician. But, I think introducing particularly the risks of the various medications and their side effects and certainly my practice is to acknowledge the benefits. You do not end up taking these kinds of combinations of things if you do not get some benefit. But I focus on the fact that that benefit is a short lived benefit and there is an accumulation of problems along with that. And so I try not to take a polarising view that one thing is good and another is bad. I think it is really important to understand that this person has taken to using these kinds of medications because there is some kind of a benefit. It is also really important to have a goal, and it has to be a shared goal about rationalising polypharmacy. I think it is actually quite tricky in someone who is still symptomatic, whether it is anxiety or depression to encourage them to withdraw a medication before introducing another treatment. But it is absolutely crucial. And again for perspective, or the message that I give at that point, is that it is actually really difficult for me to appreciate what is causing what, when someone is on multiple medications and complaining of continuing psychological distress, and that we need to gradually unravel that tangle, by taking away some of these medications. We may put them back in the future. But we need to take them away so that we can better understand it. So I try and create a safe environment to introduce why we are challenging the use of the medications and I do it in a very gradual and step-wise fashion.
The off-label prescribing. I think that is a bit of a problem in some of these individuals and I think that we will find that over time that there is an emergence of other problems associated with the off-label prescribing. So I will use the example of quetiapine. It is cropping up mostly for its sedative properties in off-label use. It is an anti-psychotic and it comes with a lot of the metabolic problems of the other novel antipsychotics. So in my parlance it is a dirty drug, because it might be sedating in the short term, but it causes a lot of problems and I think that again, if someone is using it to manage their anxiety, they are quite appreciative of an immediate anti-anxiety effect, but we really need to be sharing with the person that there are some significant long term consequences to this kind of medication.
Lastly, a regular review of the therapeutic response, the side effects and the rationale to continue. My approach is to try and renegotiate and clarify our agreed treatment goals very, very regularly with people in these kinds of situations and I keep emphasising that we are not trying to accept any records for rationalising or withdrawing medication, we are trying to get there in a way which is safe for them and if that takes the best part of a year, that is not a problem to me.
Marissa: Okay. Thanks, Murray. So we are going to go to the cases now. We have got about 20 minutes left so I am just going to go through. We are just having a little bit of trouble with the slides, so okay.
So, we have got the case up. There have been a few questions coming through. I think some of them may get answered as we work through the case, but I will try and leave some time at the end to answer anything that has been left out. So with case 1, just to recap, we have got a young woman who is having some anxiety and panic, sleep disturbance and recent social stressors with a relationship breakup, and is being prescribed by a previous GP who has retired, quetiapine and alprazolam. You have not been able to find an authority for alprazolam and she very clearly feels she will not be able to function without these. So I guess, who would like to start? The important initial steps. When you first see this patient for the first time, what is something that you should be doing in that first consult?
Tony: I will start. Murray was talking about the appropriate use of medications and one of the considerations is of course the legislation, and you know alprazolam is a medication which is now an S8 and you require authority to prescribe it and in order to gain that authority usually involves a second opinion, which is actually really quite helpful, but I suppose that is another thing to bear in mind with the use of any medications, is sticking within the legislative requirements and making that claim to patients about the issues associated with that.
Marissa: And that second opinion should be from a psychiatrist, is that right?
Tony: It usually is, yes, but I am not sure whether it specifies that in the legislation. But certainly it is a second opinion, yes. It may sometimes be an addiction person, that is all.
Marissa: Sure. And so, looking at those sort of regulatory requirements, I guess then the patient is in your room. The next thing that you sort of need to be thinking about, she has given you this history.
Tony: Well yes, again I think as Murray has spoken about, it is really important to begin to establish a therapeutic relationship with the patient and to try and take a detailed history and get to know them and get to understand both the drug and alcohol and mental health issues and all the other issues associated with this patient. But also, to be able to then be clear about you know, ultimately what the correct treatment is going to be. You know, what the right treatment in lots of ways might be. And it is never that clear-cut, but you know, you need to start to gather a lot of information. And in general practice that actually may you know, involve seeing that person over a number of consultations. One of the issues in that context is in terms of you know, gathering information. You gather information from the patient which should include a drug and alcohol history and should pay attention to whether there is any past history of substance use disorder because that always alerts me to a concern about whether someone using medications as prescribed or not, and I am not saying in this case that that is an issue, but I am always alert to the that sometimes when people are being prescribed alprazolam, they may not be using it as prescribed and you know, you do need to know things like are they getting it early, are they using extra? Are they having all those problems associated with misuse of the medication and one of the predictors of someone misusing it, is a previous history of substance misuse disorder. So that is just something to bear in mind without it being you know, necessarily dominating everything. But you are not doing anybody any favour and you are probably increasing harm if you are prescribing a medication which is being misused and increasing their risk therefore. So that is one of the considerations and the other consideration in relation to that is getting information, not just from the patient but from other sources and certainly if this person had a GP who is retired, there should be some information about previous treatments and previous investigations from those who have been involved in their care previously. So it about you know, trying to gather that information and the other thing on the initial assessment is just taking note of what you observe. I mean the history is really important. Mental health, drug and alcohol history are obviously very important, but also the examination which can be very helpful in terms of giving you information about whether everything fits together in terms of the history that someone is presenting. If someone comes in looking sedated, then yes, that gives you an indication that perhaps they are on too much medication. If someone comes in and you take their blood pressure and they have got needle marks in their cubital fossa, then gives you a certain amount of information as well. So, I know this is very much a drug and alcohol perspective, but we do have to be mindful of the fact that particularly the medications like the alprazolam which is a short-acting rapid onset benzodiazepine which is an effect which is sort after, that can be misused. So gathering all that sort of information is really important as well.
Marissa: Yes, and I think as GPs it is pretty common that we would want to be confirming history, prescription compliance with medications and prescribed dose. There is definitely a lot of questions coming through about time constraints in this first consult. You know, often people, there are time constraints for doctors, and sometimes the patients are a little bit rushed. Hopefully if it is a new patient, you might have a little bit more time to spend with them, but that can be a little bit tricky. You know, we talk about management because a lot of the questions are like, okay, so what do we do? Do we prescribe or do we not? And then also in the time frame, is there something that you can suggest in you minimising the harm from that consult to the next? So, what do you think would be a reasonable management plan for this patient and over what time period?
Tony: Again, just talking about this presentation and do you prescribe or not. I guess it depends on what information you can access, because if you are able to access information which tells you that someone has for example from a pharmacy or from wherever, that they have a prescription which is still ongoing, then it is not urgent. If this person has run out of medication then there is a question about what you prescribe then and you can take two approaches really. One is to look to you know, not prescribe a medication until you have got an authority because it is not legal, and you can prescribe something else if the person presents with withdrawal symptoms and if you monitor them regularly and they present with withdrawal symptoms, you can prescribe something. If you can confirm the treatment, then I think the other aspect before you get to know a person is to move to a staged supply in order to feel more confident in a way about whether someone is misusing a medication or not. So that can be that you actually prescribe for a very short period of time in very small amounts until you have been able to sort out what is going on. And that can be picking up daily from the chemist, which chemists do, in order to just keep things under control until you work out what is going on.
Marissa: Yes, I think we have to remember that we do not always have to give a packet of whatever the medication is, and we can definitely alter quantities on prescriptions. If someone can tell from the first consult that they are probably not going to get you know, continue therapy in this way from you, if that is all they are definitely after, you might not see them again. And that is the way it is. I think we know that there are a lot of time constraints which as I said is a lot of these questions, and it is certainly okay to give a few days’ worth of medication, particularly if you are worried about withdrawal, but then booking in a longer consult for a few days’ time and seeing what happens after that. People are asking, would you consider prescribing a small amount of an alternative benzodiazepine to maintain the therapeutic alliance in the first consult?
Murray: I would. I mean, my perspective is that she is taking a fair quantity of both quetiapine and alprazolam, so if she is not sedated and that is an accurate account of how much she is taking, then she has got a fair level of tolerance and so I would not be wanting to interrupt that until I have got some kind of rapport. So, like Tony, my number one goal is to try and engage with this person and get her to come back and not to have her feel like she is going to have the rug pulled out from under her. So I think small amounts of medication. Because at the back of this, I would be very interested to know what other treatments she has ever had. But again, as I said previously, I am n not going to ask that on day one. I am very, exquisitely aware of the time constraints in a general practice setting. So the goals need to be simple. So try and establish that this person can trust you, that you are going to work with them and you are not trying to work against them, but you are going to try and get them to the point where they realise that this is a slippery slope that they are on and that there might be other previously unexplored ways of managing these problems.
Marissa: Sure. And I guess, you know thinking about management of anxiety, if we do confirm the diagnosis, we know that probably an SSRI is probably a better medication, but the priority at this stage would be getting her off the current treatment.
Murray: An SSRI? But there are a raft of non-medication treatments which can be gotten through a mental health referral to a psychologist for cognitive behavioural therapy, mindfulness. There is a whole raft. Again, I would not introduce these the first time that I met the person, because many people will run away if they think you are going to try and sell them a non-drug alternative as the complete cure.
Tony: You were talking about different medication and certainly we tend to use diazepam to assist people to withdrawal off alprazolam if that is you know, what we are going to be doing. And it is important to understand the dose conversion in that context because alprazolam is essentially a 10:1 ratio. So diazepam 10 mg to 1 mg of alprazolam. It is important to understand its potency in order to assist someone to withdrawal. It is also important to understand that when you are doing a withdrawal program, you actually do not need to start with the full dose sometimes and so we often start with the 100% dose equivalents in terms of reducing them.
Marissa: Sure. And I think that is you know, a lot of the questions are about the authority that you need and so certainly there was a question about, can you prescribe alprazolam without authority? Someone asked, can we prescribe it as a private script and can you prescribe it without an authority for fear of withdrawal symptoms. But I think Tony has just answered that, where you can replace it with diazepam. So if you are concerned about withdrawal symptoms, diazepam will stop that from happening.
There are some good questions. We have got a lot of questions coming through and we have only got another five minutes. Look, a lot of the themes in the questions are also about referral pathways. How do we, you know, often patients cannot afford to see a psychiatrist. Certainly in Sydney where we work there is no bulk billing psychiatrists and we know that to get into the community mental health teams you need to be quite acutely unwell. Any thoughts or suggestions on that?
Murray: Look I think that is where I think the potential referral for psychological treatment or a non-drug treatment is quite helpful. Again, I appreciate that many psychologists also are not bulk billing and so there is a cost there as well. A number of those kind of non-drug treatments are actually available online. There are some online programs which are evidence based for managing some of these comorbid type conditions. I think that you know, again, the realistic scenario is that you are often the only available resource for these kinds of patients and I think that a gradual chipping away at the medication that you see as the main source of the problem and exploring the alternatives, I think is all that you are left with. Because I am not convinced that someone like this would necessarily get much of a run in sort of a public sector mental health program. They are much more attuned to managing crises and we are trying to avoid a crisis in this kind of case.
Tony: I mean I know it is not everywhere and we are talking about a range of contexts, but certainly in some drug and alcohol contexts, we do see patients like this and work with the general practitioner in terms of helping people to reduce off their medication and deal with anxiety and panic and those issues related to drug and alcohol use, because there are a range of staff that work in those contexts. So it depends on those contexts but it is not unusual for drug and alcohol specialist services to work with GPs around these and to work as a team. And sometimes GPs find that particularly helpful in terms of you know, sometimes the drug and alcohol specialist taking a more limiting role in terms of medication and them able to maintain their therapeutic alliance and work with the patient around making the changes.
Marissa: So I think we are almost out of time. I think we will go back to case 2. I think the general issues with case 2 are probably going to be similar. I think we need to think about maybe the differences in here with regards to the alcohol use. Tony did speak a lot about making that decision whether someone is suitable for withdrawal management in the community versus inpatient. Interestingly this patient also runs a gardening and mowing business, so I think we need to think about driving and the operation of machinery in patients that are using polysubstances, which was one of the points we were going to discuss. Was there anything you wanted to add specifically about the second case? We have got two minutes.
Tony: I certainly would add the issue around driving and operating machinery because I mean we talk about a range of harms from various medications and drugs, and it is a really important role of every medical practitioner to talk to the patient about the risks associated with combing activities like driving with the use of medications such as diazepam or even quetiapine. And we know there is an increased rate of accidents associated with those, and cannabis as well. So I think that is a really important one. In this context obviously, home withdrawal is slightly complicated by a low-ish dose of diazepam and it would be important to get a handle on that. He may still be amenable to that, but I think it is important to be working with other services as well.
Murray: Can I make one comment because as it is described it raises enough of a concern that he has got a very significant depression underneath all of this. Some of those symptoms indicate that he may have depression with some melancholia and in which case sertraline 50 mg is probably an inadequate dose and so I would be wanting to encourage him to particularly reduce his alcohol intake so that we can give an antidepressant a fighting chance. So my approach is to say look, I think we ought to be introducing a second line antidepressant for you such as Effexor but I do not want to do it while you are still using this much alcohol because it just will not work. But you are entitled to have a trial of something a little bit better in terms of your antidepressants. So I try to give some kind of a goal in order to have a reason to try and tackle the substance misuse.
Marissa: And you would switch to Sertraline rather than increasing the dose?
Murray: Probably. Probably. I think, obviously I would be very interested to see what happened to the symptoms as we weaned him off the alcohol and the diazepam. They are quite likely to change a lot. But the nature of the symptoms you have described there suggest an underlying significant melancholic depression. So I would be priming for probably an alternative antidepressant rather than keep boosting something which is plainly not working for him.
Tony: Again, it comes back to that importance of you know, providing lots of information about what could be potentially impacting on the mood in terms of you know, alcohol and other drugs as well as you know, all the other factors because often people do not completely understand or think through all of those issues. It is quite helpful for the GP to talk to patients about it so they can then have a reason to make some changes.
Marissa: Yes, okay. So I just wanted to make one more point which was actually quite important that the authority that we are talking about for alprazolam is from the State Pharmaceutical Services Branch rather than the PBS authority systems, so you can have a look at the Pharmaceutical Services website for information about those authorities. We have got quite a lot of questions which I think we will try and you know, address after the webinar individually. I just wanted to in summary, the main issues that we need to think about are that prescribing multiple drugs can cause harm. We do need to think about clarifying the diagnoses. Therapeutic alliance you have heard tonight from both of our specialists is really fundamental. Remember that these things take time, we are not expecting you to change things over night or in one or two consults. Always be vigilant for risky or harmful use. Psychosocial treatments as Murray said can be very effective and we need to think about them maybe a little bit more. And that specialists and GPs working together over time improves outcomes.
I am just going to give you this next slide because in New South Wales, you have access to a drug and alcohol specialist 24 hours a day, seven days a week. So there is a phone number there which is a free telephone service. It is for GPs and clinicians and a drug and alcohol specialist will answer the phone on the other end and so you can use that phone line and get advice while you have the patient in the room if you need to. There is also the New South Wales GP Psychiatry Support Line. That one is only Monday to Friday 9 to 5. You register for it online or you can do that over the phone. There is an 1800 number and that again will give you links through to a psychiatrist quickly. Anything else to add?
Sammi: That does wrap us up. We did have a lot of questions, so thanks everybody for joining us. And up on your screen at the moment there is just review of your learning outcomes and we would like to thank our presenters again for joining us, so thank you Tony, Murray and Marissa and also everybody that joined us online. We really hope that you enjoyed the session.