1 / 39

Alcohol Dependence and Detoxification

Alcohol Dependence and Detoxification. POD. Incidence/prevalence Pathophysiology Withdrawal syndromes DDx Treatment. Scope of the Problem. 8.2 million Americans are alcoholics Annual prevalence 7.4-9.7% Lifetime prevalence 13.7-23.5% 15-20% of hospitalized patients are alcoholics

zamir
Download Presentation

Alcohol Dependence and Detoxification

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Alcohol Dependence and Detoxification

  2. POD • Incidence/prevalence • Pathophysiology • Withdrawal syndromes • DDx • Treatment

  3. Scope of the Problem • 8.2 million Americans are alcoholics • Annual prevalence 7.4-9.7% • Lifetime prevalence 13.7-23.5% • 15-20% of hospitalized patients are alcoholics • 22-26% of hospital admissions are alcohol-related • 100,000 deaths/year are alcohol-related • Alcohol costs the US $100 billion/year • 15% of health care costs • 40% of alcoholics start during adolescence

  4. Enoch. Am Fam Physician 2002; 65: 441-448.

  5. Pathophysiology • 1955 study • Minor withdrawal sx if drinking 7-34 days • Major withdrawal sx in 5/6 pts while drinking for 48-87 consecutive days • Alcohol is a CNS depressant • GABA receptors downregulated by EtOH • Withdrawal unmasks compensatory CNS overactivity • Elevated norepinephrine and serotonin levels

  6. Indications for Hospitalization • Signs of severe withdrawal • History of withdrawal seizures or DTs • Multiple medical comorbidities • Coexisting depression or suicidality • Unstable home situation • Failure of outpatient treatment

  7. Consider ICU admission… • Age > 40 • Cardiac dz (heart failure, arrhythmia, angina, MI, recent MI) • Hemodynamic instability • Marked acid-base disturbances • Severe electrolyte abn (hypokalemia, hypophosph, hypomag, hypocalcemia) • Respiratory compromise (hypoxemia, hypercapnia, severe hypocapnia) • Potentially serious infections (wounds, PNA, trauma, UTI) • Signs of GI pathology (pancreatitis, GIB, hepatic insufficiency, suspected peritonitis) • Persistent hyperthermia (T>39 or 103) • E/O rhabdomyolysis • Renal insufficiency or increased fluid requirement • H/O prior EtOH withdrawal complications (DTs, seizures) • Need for high-dose sedatives or infusion to control sx Carlson R, Keske B and Cortez D. J Crit Illness. 1998.

  8. Alcohol Withdrawal • Minor withdrawal (6-48 hours) • Anxiety • Insomnia • Diaphoresis • Palpitations • Tremor • GI Upset

  9. Alcohol Withdrawal • Alcohol hallucionosis (12-48 hours) • Visual, auditory, or tactile hallucinations • Sensorium not clouded • Withdrawal seizures (48 hours) • Generalized tonic-clonic convulsions • Usually occur within 48h of last drink • 3% of chronic alcoholics have withdrawal-associated seizures • 3% develop status epilepticus • More likely in pts w/long hx of chronic alcoholism

  10. Delirium Tremens • Clinical manifestations (2-5 days) • Agitation • Disorientation • Hallucinations (predominantly visual) • Low-grade fever & diaphoresis • Tachycardia & hypertension • Hyperventilation  respiratory alkalosis

  11. Delirium Tremens • Risk factors • Age > 30 yo • Sustained daily heavy alcohol use • Prior history of DTs or withdrawal seizures • Concurrent illness • Greater number of days since last drink • Abnormal liver function • More severe withdrawal on presentation • Incidence = 5% • Mortality = 5%

  12. Delirium Tremens • Treatment • Ativan(Lorazepam) 0.5-1.0 mg IV q 5 min, or • Valium(Diazepam) 5-10 mg IV q 5 min • Until patient is calm but awake • “IV, O2, Monitors” • TOW to MICU • Younger, healthier  less sedation • Older, sicker  more sedation • Refractory….phenobarbital/propofol and mechanical ventilation

  13. Assess quantity and frequency How many years? Type of alcohol? Avg # drinks/day? Avg # days/week? Max # drinks/day in past month? Last drink? Manifestations of dependence Increased tolerance Sleep disturbance Blackouts Tremor Withdrawal sx Prior attempts to quit Family h/o alcoholism Hx

  14. CAGE Cut down Annoyed Guilty Eye-opener TWEAK Tolerance Worried Eye openers Amnesia Kut down Questionnaires

  15. Physical Exam • Tachycardia • Hypertension • Signs of trauma • Tremulousness • Rhinophyma • Hepatomegaly • Stigmata of chronic liver disease • Horizontal nystagmus? • Wide based gait (tandem walking)

  16. Labs • BAL – acute heavy drinking • Liver panel – elevated ALP, ALT, & AST • GGT – chronic heavy drinking • Lipid panel – elevated HDL & TG • CBC – elevated MCV, thrombocytopenia • Coags • Carbohydrate-deficient transferrin •  20 g/dl suggests chronic heavy drinking • Sensitivity 60-70% & specificity 80-90%

  17. DDx • Thyrotoxicosis • Anticholinergic drug poisoning • Amphetamine or cocaine use -> increased sympathetic activity • CNS infection or hemorrhage -> seizures

  18. Treatment Regimens • Front-loaded • High doses of long-acting benzo • Given until patient is symptom-free • Symptom-triggered • For lower-risk patients • Less meds & shorter stay • Fixed schedule • For higher-risk patients • More meds & longer stay

  19. Benzodiazapines • Ativan (lorazepam) • 0.5-2 mg PO or IV q4-8h • Valium (diazepam) • 5-10 mg PO or IV q4-8h • Librium (chlordiazepoxide) • 10-100 mg PO tid-qid

  20. Sample Librium Taper • Librium 50 mg PO q8h x 3 doses, then • Librium 25 mg PO q8h x 3 doses, then • Librium 10 mg PO q8h x 3 doses, plus • Librium 10-25 mg PO q4h PRN for CIWA >8. • Start taper with 100 mg dose if HR > 120, SPB > 160, or DBP > 110. • Always finish taper with 10 mg dose.

  21. What is a CIWA-Ar score? • Clinical Institute Withdrawal Assessment-Alcohol (revised) • Composed of 10 items • Each item scored 0-7, except “Clouding of Sensorium,” which is scored 0-4 • 67 points total • Score < 8 minor withdrawal • Score 8-15 moderate withdrawal • Score > 15 severe withdrawal Sullivan. Br J Addict 1989; 84: 1353-1357.

  22. Kosten. NEJM 2003; 348: 1786-1795.

  23. Sample CIWA Orders • CIWA-Ar scale q4h • 0-8 no treatment • 9-15 give ativan 1 mg or librium 25 mg po and repeat assessment in 1 hr • >15 give ativan 2 mg or librium 50 mg po and repeat assessment in 1 hr • If still > 8, give additional ativan 1 mg or librium 25 mg po and call MO **IV ativan if unable to tolerate PO**

  24. Benzodiazepine Choice • Librium 25-50mg PO q 1hr for CIWA >8 • Ativan,Librium, and Valium are also PO • Ativan for patients with Cirrhosis • Valium/Ativan are parenteral if patient is NPO

  25. Is CIWA Better? • VA Medical Center in Manchester, NH • February thru October 2002 • Alcohol detoxification unit • 101 patients (out of 280 admissions) • Symptom-triggered (n = 51) • Fixed schedule (n = 50) • Primary outcomes • Treatment duration: 9 v 68 hours • Total chlordiazepoxide: 100 v 425 milligrams • Secondary outcomes • Delirium tremens: 2% v 6% • Readmission: 6% v 8% Saitz. JAMA 1994; 272: 519-523.

  26. Is CIWA Better? • Two university hospitals in Switzerland • August 1999 thru October 2000 • Inpatient alcohol treatment program • 117 patients (out of 251 admissions) • Symptom-triggered (n = 56) • Fixed-schedule (n = 61) • Outcomes • Treatment duration: 20 v 63 hours • Total oxazepam: 38 v 231 milligrams • 39% of patients in symptom-triggered group required rx • 1 seizure, but no AH or DT, in symptom-triggered group Daeppen. Arch Intern Med 2002; 162: 1117-1121.

  27. Is CIWA Better? • Saint Marys Hospital in Rochester, MN • January 1995 thru December 1998 • General internal medicine wards • 206 patients (out of 638 admissions) • Symptom-triggered (n = 132) • Fixed schedule (n = 84) • Outcomes • Treatment duration: 45 v 56 hours • Total lorazepam: 20 v 20 milligrams • 82% of patients in symptom-triggered group required rx • 7% patients in symptom-triggered group suffered DTs Jaeger. Mayo Clin Proc 2001; 76: 695-701.

  28. Adjuvant Therapies • Propranolol (Inderal) in CAD patients • Clonidine (Catapres) – decrease autonomic sx • Carbamazepine (Tegretol) • 800mg the 1st day, tapering to 200mg by 5th day • Mild-moderate withdrawal • Decreased craving for alcohol • Not sedating/little abuse potential but little evidence for prevention seizures/delirium • Haloperidol (Haldol) • Baclofen (Kemstro) • Propofol (Diprivan) Mayo-Smith. NEJM 1997; 278: 144-151.

  29. Medications to Avoid • DO NOT USE ANTIPSYCHOTICS LIKE HALDOL • Lower seizure threshold in alcoholics • Interfere with heat dissipation

  30. Multivitamin 1 tab PO QAM Folate 1 mg PO QAM Thiamine 100 mg PO QAM x 3d then 50 mg PO QAM “Banana Bag” 1 vial multivitamin 1 mg folate 100 mg thiamine 20 mEq KCl 2 gm MgSO4 1 liter NS Nutrition

  31. Wernicke’s Encephalopathy-Korsakoff’s syndrome • Ataxia, Oculomotor Disorders, Encephalopathy • Gone unrecognized…lethargy and coma can be presenting symptom • Thiamine before glucose ALWAYS!!!! • Women more susceptible than men • Korsakoff’s • (late WE symptom/recovering from acute WE) • Anterograde & retrograde amnesia • Preservation of long term memory

  32. Comorbid Conditions • Nicotine dependence • Nicotine patch • Anxiety disorder • Benzos & SSRIs • Mood disorder • SSRIs • Suicidality • Psychiatry consult

  33. Long-Term Drug Therapy forAlcohol Dependence • Naltrexone (Revia) • Anti-craving rx • 50 mg PO daily • Disulfiram (Antabuse) • Aversive rx • 250-500 mg PO daily • Fluoxetine (Prozac) • For comorbid mood or anxiety disorder • 20-60 mg PO daily Swift. NEJM 1999: 340: 1482-1490.

  34. Whom do I call? • SARP • Office: 532-6052 • Pager: 619-553-0084 • DAPA • Office: 532-6533 • Pager: 800-471-9912 • Psychiatry • Pager: 800-471-9047

  35. Salty Resident Tips • Verify the CIWA-Ar score yourself before you increase your orders for benzodiazepines….is there a comorbid contributing to high scores? • Call Sarp/Psych early • Eliminate access to alcohol • Know your patient’s CIWA scores and benzo requirement over the last 24 hours and put it in your progress note • Low suspicion for polysubstance abuse • Contact the patient’s command ASAP

  36. Take Home • CIWA w/ativan or librium • Thiamine, MVI, IVF, replete electrolytes • Telemetry, seizure and falls precautions • SARP or Social work consult for continued treatment

  37. References • Bayard M et al. “Alcohol Withdrawal Syndrome.” AM Fam Physician 2004; 69. • Daeppen JB. “Symptom-triggered vs fixed-schedule doses of benzodiazepine for alcohol withdrawal.” Arch Intern Med 2002; 162: 1117-1121. • Enoch MA. “Problem drinking and alcoholism.” Am Fam Physician 2002; 65: 441-448. • Jaeger TM. “Symptom-triggered therapy for alcohol withdrawal syndrome in medical inpatients.” Mayo Clin Proc 2001; 695-701. • Kosten TR. “Management of drug and alcohol withdrawal.” NEJM 2003; 348: 1786-1795.

  38. References • Mayo-Smith MF. “Pharmacological Management of Alcohol Withdrawal.” JAMA 1997; 278: 144-151. • O’Connor PG. “Patients with alcohol problems.” NEJM 1998; 338: 592-602. • Saitz R. “Individualized treatment for alcohol withdrawal.” JAMA 1994; 272: 519-523. • Swift RM. “Drug therapy for alcohol dependence.” NEJM 1999: 340: 1482-1490.

  39. Special Thanks • Special thanks to LT Nelle Linz and LT Dylan Wessman for putting this presentation together and allowing me to alter it and use it as my own.

More Related