Play file: 0 – Tequila 1

Play file: 0 - Tequila 1

The Medical Management of ALCOHOL WITHDRAWAL John J. Stasinos, M.D. LTC(P), MC, USA Chief, Chemical Addictions Treatment Services Department of Psychiatry Tripler Army Medical Center 2

Disclosures I have no affiliation or financial relationship with any pharmaceutical companies The opinions stated herein are my own Off-label use of medications will be discussed I am not on any medications or mood-altering substances. 3

Outline Epidemiology Definitions Pathophysiolo gy Diagnosis Manifestations Management 4

Objectives By the end of this briefing, you will be able to Identify, assess, & diagnose patients in acute EtOH withdrawal Determine the best setting for conducting management of withdrawal symptoms Manage patients with medically complicated EtOH withdrawal Grasp systemic & administrative issues that complicate care & put patients at unnecessary risk 5

Why Are We Even Talking About This?. Joint Commission standards & policies have impacted our perceptions & decisions regarding medical management of EtOH withdrawal Disagreement persists among health care providers regarding how & where these patients are best cared for 6

What Standards?. Joint Commission recently published new standards that specifically apply to procedure of “detoxification” Standards require personnel, training, & equipment that represent considerable Some institutions sidestep the issue by declaring: “WE DON’T DO DETOX” 7

What Disagreement?. 8

The Good Patient Acknowledges illness & need for treatment Seeks out medical care appropriately Communicates clearly & transparently with health care provider Complies with treatment Responds to treatment Thanks the M.D. (& pays their medical bills) Goes away 9

But these patients Deny their illness Use up precious medical resources Can’t be reasoned with Do not comply with treatment Are unruly, agitated, uncooperative, & ungrateful Refuse potentially life-saving care And they keep coming back! 10

HOT POTATO! 11

Clinical Vignette 22 y/o SWM AD/MC E4 c hx of EtOH Dependence Brought to TAMC ER by Command escort after found to be intoxicated with EtOH ER assessment: BAL & UDS negative House staff: “We don’t do detox [at TAMC].” Pt has a grand mal seizure ICU course: seizures, delirium tremens, pneumonia, intubation & ventilation, management with iv benzos Discharged from hospital after 37 days 12

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Terminology Withdrawal Characteristic group of signs & symptoms that typically develop after rapid, marked decrease or discontinuation of a substance of dependence, which may or may not be clinically significantly or life threatening. 14

Terminology Detoxification: Interventions aimed at managing acute intoxication & withdrawal in order to clear toxins from body & minimize physical harm from substance use. Generic Marine (has he been drinking?.) 15

Terminology Detoxification: Caveat #1: The acute medical management of life-threatening intoxication & related medical problems is NOT included within the term detoxification. Caveat #2: Detox does NOT constitute substance abuse treatment for dependence but is only one part of a continuum of care for substance use disorders. Substance Abuse & Mental Health Services Administration (SAMHSA), TIP 45: Detoxification & Substance Abuse Treatment 16

Do we do inpatient detox?. Patients ARE NOT hospitalized on an elective basis for detox purposes if patient’s withdrawal symptoms can be managed in a less restrictive setting; patient has access to outpatient resources; patient has the benefit of family or other supports to monitor & provide support during detox process. We DO hospitalize patients for the clinical management of Medically Complicated Withdrawal. 17

Do we do inpatient detox?. Medical complications of substance withdrawal may be benign or lifethreatening, depending on Substance used: e.g., EtOH, Benzodiazepines, etc. Patient’s hx of prior withdrawals Patient’s age: older more severe Number & severity of medical problems Severe or high risk withdrawal requires inpatient medical treatment 18

Management of EtOH Withdrawal Consists of 3 essential components: Clinical assessment Management of medical complications of withdrawal Transition of patient into substance abuse treatment (REHAB) Intervention that does not incorporate all 3 components is incomplete & inadequate 19

EtOH Intoxication Diagnostic Criteria Recent Ingestion of EtOH Clinically significant maladaptive behavioral or psychological changes One or more of the following signs, following EtOH use: Slurred speech Incoordination Unsteady gait Nystagmus Impairment in attention or memory Stupor or coma Symptoms are not due to a general medical condition or another mental disorder 20

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Blood EtOH Levels BAL effect on function 0.1% motor coordination is impaired 0.2% user is obviously intoxicated 0.3% physical & mental activity decreases 0.35% anesthesia is present 0.4% respiratory drive is critically affected; some die 0.6% most die 23

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EtOH Withdrawal Diagnostic Criteria Cessation of (or reduction in) EtOH use that has been heavy & prolonged Two (or more) of the following, developing within several hours to a few days later: Autonomic hyperactivity (sweating, tachycardia) Increased hand tremor Insomnia Nausea or vomiting Transient visual, tactile, or auditory hallucinations Psychomotor agitation Anxiety Grand mal seizures Symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning Symptoms are not due to a general medical condition or another mental disorder 25

Pathophysiology of EtOH Withdrawal GABA (Gama amino butyric acid) Major inhibitory neurotransmitter Chronic EtOH exposure decrease in GABA A alpha 1 receptor activity NMDA (N-methyl-Daspartate) Major excitatory neurotransmitter Chronic EtOH exposure increase in NMDA receptor concentration neuron hyper excitability 26

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Pathophysiology of EtOH Withdrawal In short GABA receptor is the brake NMDA receptor is the accelerator EtOH Withdrawal is the brain accelerating without brakes. 28

Factors affecting Course of Withdrawal Severity & duration of withdrawal 1. 2. 3. 4. 5. 6. 7. depend on: Nature of substance Half-life & duration of action Length of time substance used Amount used Use of other substances Presence of other medical & psychiatric conditions Individual biopsychosocial variables 29

Blood EtOH Levels during Withdrawal 30

Course of EtOH Withdrawal 31

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Course of EtOH Withdrawal Symptom Onset after last drink Tremulousness 6 – 36 hours Hallucinations 12 – 48 hours Seizures 6 – 48 hours Delirium Tremens 48 - 96 hours 33

Tremulousness occurs within 6 – 36 hours 2ndary to autonomic hyperactivity Symptoms Tremor Anxiety Agitation Insomnia Anorexia Nausea Palpitation s Signs Tachycardia Hypertensio n Hyperreflexia Hyperthermi a Diaphoresis 34

Hallucinations Occurs within 12 – 48 hours of last drink 3 – 10% of cases develop hallucinations Duration is variable Usually visual (e.g., pink elephants) Occasionally auditory, tactile, or olfactory EtOH Hallucinosis: reality testing is intact 35

Seizures Occur within 6 – 48 hours of last drink 11-35% of patients develop seizures in hospital setting Risk correlates with duration EtOH use Manifests as grand mal tonic-clonic activity Always rule out other causes 40% are single episodes 30% of untreated patients go on to develop delirium tremens 36

Seizures EtOH is an independent risk factor for seizures Retrospective study of 308 patients in a city hospital with new onset of seizures during EtOH withdrawal EtOH (gm/day) Risk 51 – 100 3x 101 – 200 8x 201 – 300 20x 10 gm 1 beer Stephen KC. “Alcohol Consumption & Withdrawal in New-Onset Seizures.” NEJM, 1988 37

Delirium Tremens Begins 3 to 5 days after last drink Occurs in less than 5% of withdrawal patients Not always predictable or preventable Usually lasts 2-3 days, but can last up to 30 days Delirium can occur with/without “tremens” Risk factors Acute concurrent medical illness History of seizures or delirium tremens Heavier & longer EtOH history Age 60 Elevated BAL on admission (greater than 300 mg/dl) 38

Delirium Tremens Symptoms Confusion & disorientation Hallucinations Hyperresponsiveness Signs Hypertension Tachycardia Fever 39

Delirium Tremens Mortality Mortality: without treatment 20% with treatment 2 – 10% Temperature 104 45% mortality Seizures & DTs 24% mortality Cause of death Pneumonia Liver disease Hypotension Trauma 40

Clinical Assessment History Presentation Intake: amount, type, time of last drink, etc.? Hx of complicated withdrawal? Use of other substances? Medical & psychiatric history Mental Status Examination Cognitive impairment? Hallucinations? Impulsivity? Suicide/homicide risk? 41

Clinical Assessment Physical Examination Vital Signs Neurological exam Cardiovascular exam Abdominal exam Stigmata of liver disease Evidence of trauma, etc. 42

Clinical Assessment Laboratory studies Blood EtOH level Urine Drug Screen Urinalysis Blood chemistries Complete Blood Count Liver function tests & GGT PT/PTT B12 & folate assays Laboratory studies Thyroid Function Tests Beta-HCG RPR, HIV, STD screens Other studies (if clinically indicated) EKG CXray CT scan 43

EtOH Withdrawal Differential Diagnosis Acute stimulant intoxication cocaine, methamphetamine, caffeine Sepsis Thyrotoxicosis Heat stroke Hypoglycemia Intracranial processes (e.g., trauma, CVA) Encephalitis/encephalopathy 44

EtOH Withdrawal Treatment Setting Severity of withdrawal dictates level of care: Social Detoxification: 24 hour care, non-hospital/residential setting without professional medical staff Medically Supported Detoxification: 24 hour care, non-hospital/residential setting with profession medical staff Medical Detoxification: 24-hour care, hospital setting 45

Treatment Setting ASAM Criteria Level I-D: Ambulatory Detoxification Without Extended Onsite Monitoring Level II-D: Ambulatory Detoxification With Extended Onsite Monitoring Level II.2-D: Clinically Managed Residential Detoxification Level III.7-D: Medically Monitored Inpatient Detoxification (hospital ward) Level IV-D: Medically Managed Intensive Inpatient Detoxification (ICU) 46

Indications for Admission (Level III) Hx of severe withdrawal symptoms Hx of withdrawal seizures or delirium tremens Hx of heavy prolonged EtOH use with a high degree of tolerance Abuse of multiple substances Concomitant psychiatric or medical illness Pregnancy Lack of reliable support network 47

Who goes to the ICU?. (Level IV) Age 65 Significant cardiac disease Hemodynamic instability Marked acid-base disturbances Severe respiratory disease Serious infection Active delirium tremens 48

Who goes to the ICU?. (Level IV) Serious GI pathology Temp 103 F Rhabdomyolysis Acute renal failure Hx of recurrent withdrawal seizures Hx of delirium tremens IV benzodiazepine drip (Ativan 12 mg/day) 49

Treatment Strategy Reduce symptoms Prevent seizures Prevent delirium tremens Prevent &/or manage medical complications & co-morbidities 50

Supportive Care Ensure ABCs!. Secure patient in safe environment Provide IV hydration Correct electrolyte imbalances Provide nutritional support 51

Supportive Care Nursing care: reassurance, orientation Monitor for signs & symptoms of withdrawal Involve Psychiatrist on Duty (PsoD) if patient c/o suicidal/ homicidal ideation &/or psychotic symptoms 52

Role of Pharmacotherapy Stabilize psychological or physiological withdrawal symptoms Manage medical emergencies Remediate non-life threatening, relapsetriggering symptoms Stabilize co-morbid conditions 53

Thiamine & Multivitamins 30-80% of patients are deficient Thiamine does not reduce risk of seizures or delirium tremens Thiamine does reduce risk of Wernicke’s encephalopathy Give thiamine 50 – 100 mg IV or IM x 1, then po qd Administer thiamine before glucose Add MV 1 tab po qd 54

Benzodiazepines Ideal for management of EtOH withdrawal symptoms Cross-tolerance with EtOH Fairly wide therapeutic window (compared to barbiturates) Short- vs. long-acting Liver disease limits use to short acting benzos 55

Benzodiazepines Short-acting Oxazepam & Lorazepam Advantages They can be administered IM or IV (in monitored settings) They have no significant active metabolites They are metabolized & excreted principally through kidneys (& do not jeopardize alreadydamaged liver) Disadvantages They need to be administered more frequently. 56

Other Medications Beta-blockers & Clonidine Reduce autonomic hyperarousal (tachycardia, hypertension) May reduce total dosage of benzos & result in less sedation Do not reduce risk of seizures or delirium tremens 57

Other Medications Carbamazepine Reduces risk of seizure activity Does little for autonomic hyper-arousal Requires monitoring of CBC, LFTs, & serum levels Risks include liver & bone marrow toxicity 58

Other Medications Antipsychotic agents Can be used for management of agitation, aggression, & psychotic symptoms CAUTION: Can also lower seizure threshold Bottom line: other medications are best used as adjuncts instead of substitutes for benzos 59

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Routine vs. Symptomdriven Protocols Study: 100 VA patients in EtOH withdrawal Outcomes Treatment time 68 hrs vs. 9 hrs. Total dose Librium 425 mg vs. 100 mg Advantages Reduced hospital length of stay Reduced total dosage of medication Reduced cost of care Less sedation 61

Symptom-driven Protocols Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA) 10-item clinical rating system for EtOH withdrawal assessment Patient is assessed q 4 hours (while awake) CIWA can be administered in under 2 minutes Each item (but one) is scored on a scale of 0–7 Maximum score of 67 points Medicate for scores 8-10 Sullivan, JT. British Journal of Addiction, 1989; 84: 1353-7 62

Clinical Institute Withdrawal Assessment for Alcohol Scale Nausea & vomiting Tremor Sweating Anxiety Agitation Tactile disturbances Auditory disturbances Visual disturbances Headache or head fullness Disorientation 63

CIWA 64

FREE EtOH Detox Guide! Double Click Document to Open 65

Discharge Criteria Neurologically stable for last 24 hrs No withdrawal symptoms; CIWA scores 10 for last 24 hrs Vital signs are stable & within normal limits No c/o of suicidal/homicidal thoughts or behavior Detox protocol/taper must be completed; seizures are controlled Enrollment in rehab program, ideally within 24 hrs of discharge 66

P r o t r a c t e d Withdrawal Syndrome Duration 6 – 12 MONTHS Features Insomnia Depression Anxiety Irritability Mood swings Cognitive deficits 67

TAMC Process Action Team EtOH Withdrawal Protocols Membership Psychiatry Internal Medicine Family Medicine Emergency Medicine Process Literature review Discussion & collaboration 68

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Contact Information John J. Stasinos, M.D. LTC(P), MC, USA Chief, Chemical Addictions Treatment Services, TAMC Director, Addiction Psychiatry Fellowship Program (808) 433-6566 [email protected]. mil 72