March 2016 ALCOHOL WITHDRAWAL

 Recognition of alcohol withdrawal symptoms  Ensuring appropriate treatment so that complications are prevented  Describing the principles of detoxification

 Alcohol withdrawal syndrome (AWS) is a set of symptoms which occur when a person reduces or stops alcohol consumption after chronic heavy drinking  AWS is a hyperexcitable response from the CNS to lack of alcohol  Periods of acute intoxication followed by acute detoxification affect the brain profoundly and lead to seizures and cognitive deficits  Neurotoxic effects lead to adverse effects  AWS can occur in people dependent on alcohol, and in those who binge drink

 Anxiety  Tremor  Tachycardia  Hypertension  Agitation  Anorexia and nausea  Hyper-reflexia  Insomnia  Nightmares  Sweating  Hyperthermia  Disorientation  Seizures  Hallucinations  Delirium

 Patients need to exhibit 2 of the following symptoms  Increased hand tremor  Insomnia  Nausea and vomiting  Transient hallucinations  Psychomotor agitation  Anxiety  Tonic-clonic seizures  Autonomic instability

 Patients may choose to cope with symptoms rather than be labelled  Fear of being found out  Problem not presented by patients or identified by health professional  Lack of knowledge by practitioner making the assessment

 Lack of money to purchase alcohol  Undetected alcohol problem in police custody  Acute illness or injury preventing access to alcohol  Nausea or vomiting  Decision to stop drinking without medical supervision

 Symptoms and signs will start about 6-24 hours after last drink  There is peak at about hours  Severity can be mild to severe which are life threatening eg delirium, hallucinations, seizures  Severity is related to factors eg extent of consumption, duration of use, previous history of alcohol withdrawal  Differential diagnoses are: alcoholic hallucinosis, withdrawal seizures, delirium tremens  High risk of withdrawal: high blood alcohol level, pyrexia, tachycardia, physical illness, concurrent use of benzodiazepines or other drugs

 Liver function tests:  Gamma glutamyl transferase GGT  Magnesium  Full blood count (FBC)  Mean cell volume (MCV)  Clotting  Thiamine deficiency  AUDIT Alcohol use disorders identification test & AUDIT – C  FAST  CAGE  PAT  SADQ – Severity of alcohol dependence questionnaire  CIWA-Ar – Clinical Institute withdrawal assessment of Alcohol Scale

 Inpatient admission if patient has:  Severe dependence  Comorbidities  Unstable home  Polydrug users  Previous unsuccessful attempts at withdrawal  If mild dependence, with no medical complications and support at home, withdrawal can be supervised by a community alcohol team

 Chlordiazepoxide or diazepam is treatment of choice for moderate to severe dependence (assessed by SADQ and CIWA-Ar scales)  Treatment dose should be titrated to the scores on both scales  Older and young people – cautiously use lower doses and monitor  Psychosocial interventions should be administered once the patient is well enough to participate

 A medical emergency  The most severe form of withdrawal  Occurs in 5-20% patients experiencing detoxification  Occurs in 33% patients experiencing withdrawal seizures  It can be fatal in 5% patients if not treated promptly

 Most serious complication of withdrawal  Fluctuating confusion, severe tremor, autonomic features, visual and auditory hallucinations  Peak onset hours after withdrawal after cessation of drinking  Treatment includes chlordiazepoxide (see table) and may have to be administered parenterally  IM/IV pabrinex 2 pairs tds for 3-5 days  Haloperidol 0.5 – 5 mg prn for disturbed behaviour

 Peak at 48 hours post cessation of alcohol consumption  Occur in 1-15% of alcohol withdrawals  Treatment: increase dose of benzodiazepines and initiate or continue anti-convulsants

 Thiamine B1 deficiency can cause Wernicke’s encephalopathy and Korsakoff’s Syndrome  Syndrome includes: Confusion, ataxia, ophthalmoplegia  Korsakoff’s: profound short term memory defect  Untreated 20% mortality  Patients should be prescribed oral thiamine 200mg bd and vitamin Co Strong 2 tabs BD  Parenteral thiamine is given in hospital

 Peripheral neuropathy  Cardiovascular disorder: hypotension or high output cardiac failure  Mild peripheral or severe incapacitating sensor motor neuropathy  Foot drop  Distal muscle weakness or wasting  Other forms of neuropathy eg vascular, viral, trauma, carcinoma

 Patients need a lot of support after detoxification which is the start not the end of treatment  Patients need assistance to make links and appointments with agencies  Specialist agencies eg addiction services  Self help groups can be very helpful: Alcoholic anonymous, Al-Anon and Ala-teen

 Bayard, M, McIntyre J, & Hill KR, Woodside J (2004). "Alcohol withdrawal syndrome". American Family Physician 69 (6): 1443–50."Alcohol withdrawal syndrome"  Brathen G.E. et al (2005) EFNS guideline on diagnosis and management of alcohol related seizures: report of an EFNS task force. European Journal of Neurology,12 (8):  Crome, I. B & Bloor, R (2008) Alcohol problems, in Essential Psychiatry, Ed Robin Murray, Cambridge University Press.  Day, E, Copello A, Hull M (2015) Assessment and management of alcohol use disorders BMJ 2015;350:h715 Mj 2015;350:h715 Doi: /bmj.h715  Drummond C, Ghodse H, & Chengappa S. (2007). Use of investigations in the diagnosis and management of alcohol use disorders. In Clinical Topics in Addiction ed. E Day. London: Royal College of Psychiatrists.  Edwards G, Marshall J, Cook C.(2003). The treatment of drinking problems :a guide for the helping professions 4th ed. Cambridge: Cambridge University Press

 Findings (2013) Alcohol Matrix cell A3: Interventions; Medical treatment  Hall, W & Zador D (1997) The alcohol withdrawal syndrome, The Lancet; vol 349, June 28  Hughes, J.R 2009). "Alcohol withdrawal seizures". Epilepsy Behav 15 (2): 92–7"Alcohol withdrawal seizures"  Muncie HL, Jr; Yasinian, Y; Oge', L (2013). "Outpatient management of alcohol withdrawal syndrome. American family physician 88 (9): 589–95.  NICE (2011) Alcohol use disorders: diagnosis, assessment and management of harmful drinking and alcohol dependence (NICE clinical guideline, CG115)  Sech G, & Serra A. (2007) Wernicke’s encephalopathy: new clinical settings and recent advances in diagnosis management: The Lancet Neurology, 6(5)