Transcript Treating Alcohol Dependence - Home | California Society of

Treatment of Alcoholism
and Addiction
Steven R. Ey, M.D.
Medical Director
Genesis Chemical Dependency Unit
South Coast Medical Center
Laguna Beach, CA
April 14, 2005
Addiction Reward Pathway
Admission Labs
 Labs (BAL, CBC, Chem 22, Mg, TSH, RPR,
lipase, UDS, UA, pregnancy test)
 PPD
 CXR
 EKG
 Acetaminophen and salicilate level as
indicated
Absorption and Metabolism
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Sites include stomach, small intestine, and colon
Dependent on gastric emptying time
Metabolized primarily in the liver by oxidation
Alcohol dehydrogenase exhibits zero-order kinetics
(15 mg/dl/hr)
 Proportional to body weight
 Microsomal ethanol oxidizing system (MEOS)
 Alcohol inhibits cytochrome P-450
Alcohol Breakdown
 Alcohol
ADH
Acetaldehyde
ALDH
Acetic acid and water
Alcohol Intoxication
 20-99mg% loss of muscular coordination,
change in behavior
 100-199mg% ataxia, mental impairment
 200-299mg% obvious intoxication, nausea
and vomiting
 300-399mg% severe dysarthria and amnesia
Alcohol Intoxication cont.
 400-600mg% coma occurs
 600-800mg% decreased respirations and
blood pressure, obtundation, often fatal
 Important to remember the role of tolerance
in all these categories
Management of Alcohol
Intoxication
 Cardiovascular and respiratory support to control
blood pressure and maintain airway
 Intravenous fluids (“Banana Bag-NS, thiamine,
MVI, Folate, B-12)
 Assess for other drug use especially benzo’s or
opioids as antagonists can be used
 Closely monitor until withdrawal begins and then
start treatment
Monitoring Alcohol
Withdrawal
 MSSA (Modified Selective Severity
Assessment)
 CIWA-A (Clinical Institute Withdrawal
Assessment for Alcohol)
 Advantage for personnel to monitor progress
and treat accordingly
 Disadvantage is cookbook approach
Withdrawal Signs and
Symptoms
 Tremor
 Agitation
 Autonomic changes (BP, HR, Temp.)
 Seizures
 Sensorium changes (eg, hallucinations,
confusion)
Withdrawal Syndrome Stage 1
 Begins within 24 hours
 Lasts up to 5 days
 90% of cases do not go beyond stage 1
 Other symptoms include depressed mood,
anxiety, diaphoresis, headache,
nausea/vomiting, etc.
Withdrawal Syndrome Stage 2
 Mostly untreated or undertreated in stage 1
 Same signs and symptoms in stage 1 only
more severe
 Hallmark is hallucinations (generally
perceived as benign)
 Usually occurs 48 hours after last drink
Withdrawal Syndrome Stage 3
 Usually occurs 72 hours after last drink
 Delirium Tremens (acute reversible organic
psychosis) has 2% mortality
 Lacks insight into hallucination, often
disoriented and labile
 Seen in persons with severe alcoholism
and/or significant medical problems
Detoxification Treatment
 Begin benzodiazepine at onset of withdrawal
symptoms
 Be cautious that symptoms are withdrawal
and not intoxication
 If uncertain repeat BAC to be sure it is
decreasing before sedating detoxification
meds are instituted
Detox Pharmacology
 Benzodiazepine and Barbiturate equivalents:
 Diazepam 10mg
 Lorazepam 2mg
 Phenobarbital 30mg
 Chlordiazepoxide 25mg
 Oxazepam 30mg
Detox Pharmacotherapy
 Know 2-3 drugs well for routine detox (e.g.,
Diazepam 10-20 mg Q1 hr prn withdrawal)
 Magnesium sulfate 2 gm for severe withdrawal
(esp. in seizure risk)
 Daily thiamine 100 mg, folate 1mg, and MVI
 Push fluids
 Supportive therapy (eg hypertension meds, etc.)
 Stage 3 withdrawal usually requires iv fluids, foley
catheter, soft restraints, etc.
Alcohol Withdrawal Seizures
 More common in untreated alcoholics
 Should hospitalize if first seizure
 Need to be evaluated for other causes (eg, head
injury, CVA, or CNS infection, etc.) if first seizure
or history not clear
 Work up includes brain imaging and EEG
 1 in 4 patients have a second seizure within 6-12
hours
 Must report any seizure to County Health Dept. and
inform patient not to drive
Alcohol Withdrawal Seizures
 Mostly Grand mal seizures
 Usually 24-48 hours after last drink but may
be within 8 hours
 BAC does not have to be zero
 Less than 3% become status epilepticus
 Increased risk if prior seizure or detoxing off
sedative hypnotic as well
GABA and NMDA Neuronal
Receptors
Substance Abuse, J Lowinson, MD.
Third Edition, 1997, page 129.
Kindling and Seizures
Alcohol Withdrawal Seizure
Treatment
 Parenteral benzodiazepines (eg, ativan 2 mg or
valium 10 mg iv stat)
 Seizure precautions
 Valium 10-20 mg q1 hour prn or scheduled taper
 Anti-convulsants are generally not indicated unless
the diagnosis is in doubt
 Work up if 1st seizure
 Report to County Health Dept. and no driving until
cleared
Pharmacotherapy Treatment
 Disulfiram
 Naltrexone
 Acamprosate
Disulfiram
 Deterrent therapy
 Inhibits metabolism of alcohol by blocking
acetaldehyde dehydrogenase
 Acetaldehyde is toxic product causing the reaction
(flushed, tachycardia, diaphoresis, nausea,
headache, etc.)
 Metronidazole and alcohol may cause disulfiram
like reaction
Disulfiram (cont.)
 Prescribing tips (read the label for alcohol if
not sure)
 Monitor liver enzymes
 May cause psychosis
 Evaluate need for patient to take in front of
staff
Naltrexone
 Opiate blocker
 Evidence for reduced cravings and relapse
rates
 23% relapsed vs. 54% placebo during 12
week study
 Definition of relapse
Volpicelli, 1992
Naltrexone cont.
 VA study Dec 13, 2001 NEJM
 627 veterans given 12 mo Naltrexone, or 3
mo. Naltrexone and 9 mo placebo, or 12 mo
placebo
 No statistically significant difference in #
days to relapse at 13 weeks, and no
difference in % days drinking at 52 weeks
Krystal, et al. NEJM Volume 345, pg.
1734-39, Dec 13, 2001
Acamprosate
 Affinity for GABA A and GABA B receptors
 Inhibits glutamate effect on NMDA receptors
 Now available in the United States
Acamprosate cont.
 Multiple studies in Europe show it effectiveness
and safety
 Tempesta, et al. (2000) found abstinence rate 57.9%
with acamprosate versus 45.2% with placebo
 Sass, et al. (1996) found at the end of 48 weeks of
treatment and 48 more weeks of follow-up that 39%
of the acamprosate group vs. 17% of the placebo
group remained abstinent
Case Scenario #1
 40 y.o. male admitted with BAC 460 mg/dl.
 Communicates clearly
 History of recent Alcohol Withdrawal
Seizure
 History of multiple AMA’s during detox in
the past
Case Scenario #1 Treatment
 Patient has high tolerance so medicate appropriately
 Monitor closely and repeat BAC to ensure it is
decreasing
 May use Librium 100 mg po or Phenobarbital 130
mg im to decrease risk of seizure
 Start valium 10-20 mg q 1 hour prn (or Ativan)
 Begin thiamine 100 mg, folate 1 mg, & MVI daily
 2 gm MgSO4 if withdrawal difficult or Mg low
 Consider Depakote or Dilantin but not necessary
Case Scenario #2
 55 y.o. female drinking 1 bottle wine per day
and taking xanax 4 mg. per day
 Smokes 1 pack per day cigarettes
 Complains of hip pain, fell 1 week ago
Case Scenario #2 Treatment
 Alcohol detox with usual meds or Phenobarbital
 Slow klonopin taper as outpatient is one option but
there are more (eg anti-seizure meds and quick
taper in hospital) to detox off of Xanax
 Smoking cessation program
 Don’t forget to check the hip pain.
Case Scenario #3
 30 y.o. female drinking 1-2 bottles of wine
per day
 History of Bulimia nervosa, last binge/purge
3 months ago
 History of multiple relapses
Case Scenario #3 Treatment
 Pregnancy test positive!
 OB/GYN consult but you can order an
ultrasound now
 Always treat as if they will keep the baby
 Detox med of choice is Phenobarbital
 Extended care in dual diagnosis program
Opioid Dependence
 Physiologic dependence versus addiction
 Common opioids
 Rx drugs on the streets, etc.
 Abuse patterns
Opioid Withdrawal Signs
 COWS Scale
 Elevated HR & BP, diaphoresis, restlessness,
pupil size, bone or joint aches, runny nose or
tearing, GI upset, tremor, yawning, anxiety
or irritability, gooseflesh skin
 Score items stage to withdrawal
Opioid Treatment
 Clonidine 0.1 mg every 2 hours prn
 Benzodiazepine or barbiturate prn (eg,
Phenobarbital 15-30 mg every 3 hours prn)
 NSAID
 Muscle relaxant (eg, methacarbamol)
 Bentyl for abdominal cramps
 Sleeping agent (eg, temazepam)
Opioid Treatment (cont.)
 Subutex (buprenorphine)
 Suboxone (buprenorphine/naloxone)
 Sublingual administration of partial opioid
agonist
 Must be certified through DEA to use
Treatment with Suboxone
 Certification requires ASAM, Addiction
Psychiatry, or 8 hour training course
 Capacity to provide or to refer patients for
necessary ancillary services
 Treat no more than 30 patients at one time
Opioid Case #1
 45 y.o. female taking increasing doses of
hydrocodone per day
 Currently on 90 mg per day
 Repeatedly calling office, loses prescriptions
 No pain etiology to explain use of narcotics
Opioid Case #1 Treatment
 Recommend inpatient detox in CD program
 Consider outpatient detox only in reliable,
motivated patient
 Clonidine 0.1 mg q 2 hrs. prn, NSAID,
Muscle relaxant, bentyl, benzo’s for anxiety
and insomnia
 Most CD programs using suboxone now
Sedative/Hypnotic Dependence
 Difficult to detox
 Seizure prophylaxis important
 Rebound anxiety needs to be treated
 Methods to obtain meds include legitimate
prescriptions, prescription fraud, multiple
MD’s or clinics, internet, foreign countries
and the street
Sedative/Hypnotic Treatment
 Taper as outpatient 10% of dose per week as
outpatient
 Quick taper as inpatient with anti-seizure
meds
 Consider valproic acid or other anti-seizure
med for equivalent doses of valium 30 mg.
per day or more (based on clinical
experience)
Sedative/Hypnotic Case #1
 32 yo male taking xanax for 3 years
 Began with xanax 0.5 mg. BID
 Now taking 6 mg. per day for 3 months
 Also on SSRI
 No history of seizure
Sed/Hyp Case #1 Treatment
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Equivalent dose of valium 60 mg. per day
Likely to have seizure if stops abruptly
Recommend inpatient detox
Start valproic acid 250 mg. QID, keep on
therapeutic dose minimum 6 weeks
 Substitute benzo or barb with limited doses for 5-7
days
 Consider zyprexa or equivalent
 Continue SSRI
Psychostimulants
 Detox not a covered benefit
 Medical complications usually bring patient
to ER
 May admit for workup of Chest pain, CVA,
seizure, etc.
 Referral to program
Nicotine
 Fagerstrom Test
 Nicotine Replacement (gum, patches)
 Bupropion
 Support Groups