Alcohol: Research to Practice

Gail D’Onofrio MD, MS Section of Emergency Medicine Yale University School of Medicine

Case Study

Mr. Smith is a 35 year old white male who presents with a new onset seizure this morning. He has no known past medical history, and takes no regular medications. He does not have a primary care physician

Initial Management

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History

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Physical Exam

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Laboratory tests

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Diagnostic Imaging

GABA GABA A Receptor glutamate NMDA receptor NO Cl Ca++ Cl Glycine Receptor

CNS Neuron

Ca+ + VOCC L,N

Alcohol Dependence

3 or more of these criteria in a 12-month period: 1. Tolerance 2. Withdrawal 3. More or longer consumption than intended 4. Cannot cut down or control alcohol use 5. A great deal of time getting, using, recovering 6. Activities given up or reduced 7. Use despite knowledge of health problem (3-7) Loss of control/preoccupation

American Psychiatric Association DSM IV, 1994

Alcohol-Related Seizures

 Adult onset seizures occurring in the setting of chronic alcohol dependence

Historical perspective

 Hippocrates 400 B.C. - first description  Isbell 1955 - first experimental study  Victor and Brausch 1967 - landmark study

Alcohol-Related Seizures Withdrawal

 Recurrent detoxifications and prior seizure are risk factors  Occur 24-48 hrs after abstinence or decreased intake  Often occur prior to autonomic hyperactivity  Generalized, single or a few over a short time – < 3% status epilepticus – 79% < 3 – 86% recurrent seizure within 6 hrs Victor and Brausch. Epilepsia 1967;8:1,

Differential diagnosis

 Structural brain lesions Stroke & traumatic brain injury. Susceptibility due to cerebral atrophy and head trauma  Toxic-metabolic disorders Alkalosis, hypomagnesemia, hypoglycemia & illicit drug use

Differential diagnosis

 Alcohol withdrawal – underestimated as a cause of generalized seizures  Idiopathic generalized epilepsy - poor seizure control in alcohol dependence  Sleep deprivation & medication compliance

Pathogenesis

 Biochemical effects of alcohol on CNS  Kindling - increased susceptibility and severity of recurrent withdrawal episodes.

 Brown 1988 – no. of prior detoxifications a risk factor

Exacerbation of idiopathic generalized epilepsy Other predisposing factors causing acute symptomatic seizures, e.g., associated drug abuse

Alcohol

Epilepsy related to other risk factors associated with chronic alcohol abuse, e.g.

traumatic brain injury Alcohol-withdrawal seizures Alcohol-intoxication seizures

Diagnostic evaluation

 Screening for alcohol dependence  Laboratory testing –rarely changes management.

 Earnest 1988 - head CT indicated for all patients with new-onset alcohol-related seizures  Sand 2002 – EEGs on all patients

Seizure Recurrence

• • • • 186 subjects with alcohol withdrawal seizures RCT, double blinded 2 mg of lorazepam IV Also decreased hospital admission

50 40 30 20 10 3 0 lorazepam 24 % with 2nd seizure

D'Onofrio G et al. N Engl J Med 1999;340:915-919.

Treatment of Alcohol Withdrawal

Alcohol Withdrawal (DSM-IV)

• • Cessation or reduction in alcohol use that has been heavy/prolonged – – – – Two or more of the following, developing in hours-days, causing distress or impairment, not due to other condition – – Autonomic hyperactivity (sweating, tachycardia) Increased hand tremor – – Insomnia Nausea or vomiting Transient tactile, visual or auditory hallucinations or illusions Psychomotor agitation Anxiety Grand mal seizures

Detoxification: Inpatient versus Outpatient with mild/moderate alcohol withdrawal (RCT)

Completing treatment (%)*

OUTpt (N=87) INpt (N=77)

72 95 Abstinence (1 month)(%)** No Intoxication (1 month)(%)* Abstinence (6 months)(%) No Intoxication (6 mo)(%) Days of treatment (mean)* Cost ($)* 66 76 48 59 4.5

175-388 81 88 46 51 9.2

3319-3665 No difference in Addiction Severity Scores

*p<.001, **p<0.03. Hayashida et al. NEJM 1989;320:358

Pharmacologic Therapies for Alcohol Withdrawal

Treatment Phase and Drug Class Alcohol Withdrawal

Benzodiazepines diazepam (10-20 mg) chlordiazepoxide (50-100 mg) lorazepam (2-4 mg every 1-2 hr until symptoms subside [e.g., CIWA-Ar score <8] for 24 hr*)

Examples

Chlordiazepoxide* Diazepam* Oxazepam* Lorazepam and others

Mechanism & Effects

Decrease hyperautonomic state by facilitating inhibitory y aminobutyric acid receptor for transmission, which is down regulated by long term exposure to alcohol Sedation * Drug has a Food and Drug Administration-approved indication for this use in the US O’Connor P, et al. NEJM 1998;338;9;592-602

Pharmacological Therapies for Alcohol Withdrawal

Treatment Phase and Drug Class Alcohol Withdrawal

Beta-blockers Alpha-agonists Antiepileptics

Examples

Atenolol Propranolol Clonidine Carbamazepine

Effects

Improvement in vital signs; reduction in craving Decreased withdrawal symptoms Decreased severity of withdrawal; prevention of seizures O’Connor P, et al. NEJM 1998;338;9;592-602

CIWA-Ar

CIWA-Ar denotes:

Clinical Institute Withdrawal Assessment for Alcohol, revised. The scale assesses 10 domains (nausea or vomiting; anxiety; tremor; sweating; auditory, visual, and tactile disturbances; headache; agitation; and clouding of sensorium) and assigns 0 to 7 points for each item except for the last item, which is assigned 0 to 4 points, with a total possible score of 67. This scale has been validated as a measure to assess the severity of alcohol withdrawal. Higher scores indicate a higher risk of complications; patients receiving scores of 8 or more should be treated.* *Mayo-Smith MF. JAMA 1997;278:144-51.

Symptom-triggered Therapy

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101 adults with no past seizures hospitalized for alcohol withdrawal

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Placebo or Chlordiazepoxide 50 mg qid X4 then 25 mg qid X8 (double blind)

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ALL: Chlordiazepoxide 25-100 mg q 1 hour as needed (objective scale: CIWA-Ar)

Saitz R et al JAMA 1994;272:519-23

Decreased Duration of Treatment

Saitz R et al JAMA 1994;272:519-23

ASAM Practice Guidelines Treatment approaches

• •

Monitor

q 4-8 hrs until symptoms improved

Symptom-triggered

(q 1 when CIWA>8) • Chlordiazepoxide 50-100 mg • Diazepam 10-20 mg • Lorazepam 2-4 mg •

Fixed schedule

(q 6 for 4/8 doses + PRN) • Chlordiazepoxide 50 mg/25 mg • Diazepam 10 mg/5 mg • Lorazepam 2 mg/1 mg

Mayo-Smith and ASAM working group JAMA 1997;278:144-51 Saitz and O’Malley Med Clin N A 1997;81:881-907

Treatment of Alcohol Dependence

Detoxification is NOT treatment

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Behavioral Counseling

– –

Motivational Cognitive-behavioral (Cue exposure, contingency management, coping skills

– –

12 step Psychotherapy

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Pharmacotherapy

Treatment Does Work

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2/3rds of patients (1-year) reduce:

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Consequences of alcohol consumption (injury job loss)

–

Amount of consumption by > 50%

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1/3 of patients treated are either abstinent or drink moderately without consequences

Miller WR, Walters ST, Bennett ME. How effective is alcoholism treatment in the US? J Stud Alcohol 2001;62:211-20

Success Rates for Addictive Disorders

Disorder Alcoholism Success Rate (%)* 50 (40-70) Opioid Dependence Cocaine Dependence Nicotine Dependence 60 (50-80) 55 (50-60) 30 (20-40)

* Follow-up 6 mo. Data are median (range) O, Brien C; McLellan A. Lancet 1996;347;237-40

Compliance and Relapse in Selected Chronic Medical Disorders

Compliance and Relapse IDDM (Insulin-dependent diabetes mellitus) Medication Regimen Diet and Foot Care Relapse* Hypertension

+

Medication Regimen Diet Relapse* Asthma Medication Regimen Relapse* <50% <30% 30-50% <30% <30% 50-60% <30% 60-80%

*Retreatment within 12 mo by physician at emergency room or hospital; + Requiring medication O, Brien C; McLellan A. Lancet 1996;347;237-40

Self Help/Mutual Help

Alcoholics Anonymous (AA)

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Provides support at no charge

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Veteran study shows higher frequency of abstinence at 12 months than those programs with CBT (26% vs 19%)

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Participation in AA associated with higher rates of abstinence 7 months after inpt tx compared with no participation.

Quimette PC, et al. Twelve-step and cognitive-behavioral treatment for substance abuse: a comparison of treatment effectiveness. J Consult Clin Psychol 1997;65:230-40.

Montgomery HA et al. Does AA involvement predict treatment outcomes? J Subst Abuse Treat 1995;12:241-6.

AA

1. We admitted we were powerless over alcohol - that our lives had become unmanageable.

2. Came to believe that a Power greater than ourselves could restore us to sanity.

3. Made a decision to turn our will and our lives over to the care of God as we understood Him.

4. Made a searching and fearless moral inventory of ourselves.

5. Admitted to God, to ourselves and to another human being the exact nature of our wrongs.

6. Were entirely ready to have God remove all these defects of character.

AA (continued)

7. Humbly asked Him to remove our shortcomings.

8. Made a list of all persons we had harmed, and became willing to make amends to them all.

9. Made direct amends to such people wherever possible, except when to do so would injure them or others.

10. Continued to take personal inventory, + when we were wrong promptly admitted it.

11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.

12. Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics and to practice these principles in all our affairs.

Behavioral Therapy

Project MATCH

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Subjects recruited after inpatient treatment or outpatient treatment

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Randomized to MET, CBT or 12-step facilitation, over 12-week period

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Little difference in outcomes by type of Treatment

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Aftercare after inpatient stay: 12-month continuous abstinence 35%, 40% relapsed to 3 consecutive heavy drinking days

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Outpatients, 19% abstained, and 46% relapsed

Project MATCH Research Group.

J Stud Alcohol 1997;58:7-29

Pharmacotherapy

Pharmacologic Therapies for Alcohol Prevention Relapse

Treatment Phase and Drug Class Examples Effects Prevention of Relapse Alcohol sensitizers Opioid antagonists Disulfiram* Naltrexone* Decreased alcohol use among those who relapse Increased abstinence, decreased # of drinking days Homotaurine derivatives Acamprosate Increased abstinence

* Drug has a Food and Drug Administration-approved indication for this use in the US O’Connor P, et al. NEJM 1998;338;9;592-602

Medications for Treatment of Alcohol Dependence to Prevent Relapse

Medication DISULFIRAM

Antabuse (Initial dose, 250 mg daily; therapeutic dose, 500 mg daily)

Presumed Mechanism of Action

Blocks acetaldehyde dehydrogenase; blockade allows acetaldehyde to accumulate with alcohol consumption, causing unpleasant symptoms (e.g., flushing, headache, vomiting, dyspnea, confusion)

Side Effects

Idiosyncratic fulminant hepatitis, neuropathy (at doses >500mg), psychosis, and symptoms that generally resolve on discontinuation of drug (headache, drowsiness, fatigue, rash, pruritus, dermatitis, garlicky taste in mouth)

Contraindications:

wait 24 hours after drinking, elderly, varices, confusion, HTN Rx Saitz R NEJM 2005;352;6;596-607

Disulfiram

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Multicenter RCT, 12-month F/u of N=605

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DS 250mg, 1 mg, or none

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No difference in abstinence

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More abstinence in those adherent to DS (43% vs. 8%,p<0.001)

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Fewer drinking days in the 162 assigned to DS, adhered, and completed F/u, compared to other groups (p=0.05)

Fuller RK JAMA 1986;256:1449

Disulfiram

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Daily or just prior to risky situation

–

Duration of action: 4-7 days, up to 14

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Monitor LFTS (2 wks, 3,6 Mo, 1yr), avoid alcohol in OTC meds, interacts with warfarin, INH and anticonvulsants

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Contraindications

– –

alcohol within 24 hours Elderly, pregnancy, varices, confusion, seizures, heart disease, anti-HTN therapy, (ie. anti-adrenergics

Medications for Treatment of Alcohol Dependence to Prevent Relapse

Medication NALTREXONE

ReVia (initial dose 12.5 mg daily or 25 mg daily; therapeutic dose 50 mg daily)

ACAMPROSATE

Campral (666 mg 3 times a day)

Presumed Mechanism of Action

Acts as an opiate agonist; decreases heavy drinking by blocking endogenous opioids, a process that attenuates craving and the reinforcing effects of alcohol Increases abstinence by stabilizing activity in the glutamate system, which is affected by long-term heavy consumption

Side Effects

Nausea, headache, dizziness, nervousness, fatigue, insomnia, vomiting, anxiety, somnolence, dry mouth, dyspepsia, elevated liver enzyme levels (dose-related), difficult pain management

Contraindicated:

opiate dependence, pregnancy, liver disease Diarrhea

Contraindications:

insufficiency Renal Saitz R NEJM 2005;352;6;596-607

Naltrexone

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A meta-analysis showed that in RCTs of a short duration (< 3 months)

–

decreased the risk of a return to heavy drinking from 48% to 37%

–

Decreased drinking days by 4.5%

–

Proportion of patients who were abstinent was higher with naltrexone than placebo (35% vs. 30%); borderline significance

Carmen B et al. Addiction 2004:99:811-28

Naltrexone

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Can be prescribed in the context of psychosocial treatments for those with alcohol dependence, not drinking. Last drink 5-30 days ago, LFTs < 3x normal, no opiates

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Less drinking, less relapse 12.5 mg →25mg →50mg over first few days

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Med Alert bracelet, stop 3 days pre-op

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Monitor LFTs, drinking and SEs monthly

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? Duration of treatment

Back to Our Patient

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Treatment of ARS

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Brief Intervention: Goal is to link with specialized treatment center for initial detoxification

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Referral to primary care

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Long term treatment through behavioral and/or pharmacotherapy

Thanks



Richard Saitz MD, MPH



Niels Rathlev, MD Boston University School of Medicine