Managing Alcohol and Opioid Withdrawals

Slides:



Advertisements
Similar presentations
Alcohol: Research to Practice Gail D’Onofrio MD, MS Section of Emergency Medicine Yale University School of Medicine.
Advertisements

Best Practice Tom Shiffler, MD 7/23/10
Community Alcohol Detoxification Dr Merlin Willcox, Luther St Medical Centre, Oxford.
UNMH Alcohol Withdrawal Protocol Based on and adapted from alcohol withdrawal protocol at Bayfront Medical Center CriticalCareNurse Vol 30, No. 3, June.
Saving Lives By Strengthening Our Region’s Trauma Care System December 5, 2013 MANAGEMENT OF THE INJURED PATIENT IN ALCOHOL WITHDRAWAL.
Toxin-Induced Seizures: Life-Threatening Forms of Withdrawl ACEP Scientific Assembly 2003, Boston, MA.
Detoxification Pharmacology Rochelle Head-Dunham, M.D., FAPA Medical Director, Louisiana Office for Addictive Disorders.
Copyright © 2002 by W. B. Saunders Company. All rights reserved. Chapter 27 Care of the Chemically Impaired Menu F.
Developed for the Alcohol Medical Scholars Program 1 Alcohol and Cocaine Katie McQueen, M.D. Baylor College of Medicine.
Joanna Piechniczek-Buczek, MD Boston University
By : dr.noor Alcohol& related mental disorders By: Dr.Noor.
Chapter 8: Chronic Alcohol Third leading preventable cause of death in the US.
Alcohol Medical Scholars ALCOHOLISM AND POSTTRAUMATIC STRESS DISORDER Joe E. Thornton, M.D.
Copyright Alcohol Medical Scholars Program1 SUBSTANCE USE DISORDERS IN GERIATRIC PATIENTS Steven H. Madonick, M.D. Yale University School of Medicine New.
Delirium Tremens Jaymie McAllister EBP Presentation November 5, 2012.
Management of Alcohol Withdrawal
Alcohol Pharmacology Acute and Chronic use and the effects on Anaesthesia Alcohol withdrawal.
7: Managing withdrawal Objectives
Keri Holmes-Maybank, MD Cathryn Caton, MD, MS MUSC June 21, 2012
TRAUMA CARE BEYOND THE ED
Drug-Induced Seizures (in 15 minutes or Less) Robert S. Hoffman, MD Director, NYC Poison Center Associate Professor Emergency Medicine and Medicine NYU.
Inpatient Management of Alcohol Withdrawal
Delirium: A Disturbance of Consciousness By Amy Wisniewski, RN, CCM, BSN Nursing made Incredibly Easy! January/February ANCC/AACN contact hours.
A LCOHOL USE DISORDER. A LCOHOL USE IN I NDIA 21% of adult males use alcohol (Ray et al, 2004) 5% women use alcohol (Benegal et al, 2005) 50% of all drinkers.
Downers and Dual Recovery How do depressant drugs affect mental health?
CIWA Protocol: Fraser Health
An Educational Perspective Based on Information Contained In The Indiana Prevention Resource Center Factline on Benzodiazepines ®
Chapter 9 Alcohol Acute effects Mechanisms of action Long-term effects
 BNZ-1 r.: sedation, hypnotic, antianxiety  BNZ-2 r.: anxiolysis, muscle relaxation, sedation, anticonvulsant, psychomotor impairment  BNZ-3 r.: tolerance,
Alcohol Withdrawal Resident Rounds July 10, 2007 Maggie Gordon, R2.
PHARMACOLOGY CNS 2 ANXIOLYTICS, HYPNOTICS AND SEDATIVES
Drugs used in treatment of addiction
Alcohol Withdrawal Syndrome
RLS Slide Library Version All Contents Copyright © WE MOVE 2001 Restless Legs Syndrome: Classification, Diagnosis and Approaches to.
Copyright © 2008 Lippincott Williams & Wilkins. Introductory Clinical Pharmacology Chapter 22 Antianxiety Drugs.
James B. Ray, PharmD, CPE The James A. Otterbeck Professor of Hospice & Palliative Care University of Iowa College of Pharmacy 11/18/2015.
Alcohol Withdrawal Syndromes
Clinical Management Course: Medical Complications of Alcoholism Peter R. Martin, M.D. Professor of Psychiatry and Pharmacology.
Liaison and Emergency Psychiatry Moray 1 Alcohol dependence and Safe Withdrawal In-patient detox in Dr Grays.
Treatment of Alcohol Withdrawal
March 2016 ALCOHOL WITHDRAWAL.  Recognition of alcohol withdrawal symptoms  Ensuring appropriate treatment so that complications are prevented  Describing.
Samantha Allen PharmD Candidate 2012 Case Presentation April 19, 2012 Alcohol Withdrawal Management.
Patty Ghazvini, PharmD., CGP. Associate Professor of Pharmacy Practice FAMU College of Pharmacy.
SUBSTANCE ABUSE Substance: any drug, medication, or toxin that shares potential for abuse Addiction: physiologic/psychologic dependence causing withdrawal.
Parenteral Vitamin Repletion in Alcohol Use Disorder Vicki P. Cheng, Cory Taylor UCI Internal Medicine Residency Cost-Conscious Medicine Series.
ALCOHOL WITHDRAWAL: PATHOPHYSIOLOGY, DIAGNOSIS AND TREATMENT
Common Presentations Depression With or without suicidality Adjustment reactions Mania Psychosis Intoxication Withdrawal.
INTRODUCTION Acute alcohol withdrawal syndrome occurs when individuals with alcohol dependency abruptly stop or substantially reduce their alcohol consumption.
1 Play file: 0 - Tequila. 2 The Medical Management of A LCOHOL W ITHDRAWAL John J. Stasinos, M.D. LTC(P), MC, USA Chief, Chemical Addictions Treatment.
 Discuss the symptoms and signs of alcohol withdrawal.  Discuss the management of alcohol withdrawal.
Alcohol and Other Drug Emergencies
Alcohol Awareness: what every GP needs to know
ALCOHOLISM Alcoholism is a chronic disease characterized
Managing Alcohol and Opioid Withdrawals
Alcohol Detoxification
Across the Continuum….. Managing the Inpatient
Following this training the nurse will be able to:
Update Training on CIWA and COWS
Complex Management of Gamma Hydroxyl Butyrate Withdrawal
Analysis of Safety and Efficacy of Dexmedetomidine as Adjunctive Therapy for Alcohol Withdrawal in ICU Vincent Rizzo MD MBA FACP Ricardo Lopez MD FCCP.
Alcohol Withdrawal in Acute Care
UCI internal medicine mini-lecture series By Julia Kao
Chapter 38 Drug Abuse II: Alcohol 1.
Alcoholism and unhealthy use
Treating Alcohol Withdrawal
Delirium
Alcohol Use Disorder Assessment & Treatment Strategies
Substance-Related Disorders Part II
PHARMACOTHERAPY - I PHCY 310
Acute Pain Management & Addiction
Presentation transcript:

Managing Alcohol and Opioid Withdrawals Pouneh Nasseri MD Chief resident

Goals of lecture Recognize alcohol and opioid withdrawal in the inpatient setting Management of withdrawal in the inpatient setting

Alcohol use terminology Standard drink Approximate # of standard drinks in: Equivalents:

Recognizing alcoholism Terms used: alcohol abuse, alcohol dependence, alcohol use disorder Typical characteristics Impaired control over drinking Preoccupation with alcohol Use of alcohol despite adverse consequences Distortions in thinking, most notably denial Different screening tools: CAGE Alcohol use disorder identification Test (AUDIT) or AUDIT-C AUDIT AUDIT C CAGE

How many drinks are too many? The National Institute on Alcohol Abuse and Alcoholism (NIAAA) definition: Men under age 65 More than 14 standard drinks per week on average More than 4 drinks on any day Women, adults 65 years and older More than 7 standard drinks per week on average More than 3 drinks on any day amounts of alcohol that increase health risks

Alcohol Withdrawal Pathophysiology ETOH = Depressant Sudden cessation causes CNS hyperactivity Enhances inhibitory tone (via modulation of gamma-aminobutyric acid activity) Inhibits excitatory tone (via modulation of excitatory amino acid activity). GABA is a inhibitory system in CNS Chronic ethanol use induces an insensitivity to GABA such that more inhibitor is required to maintain a constant inhibitory tone . As alcohol tolerance develops, the individual retains arousal at concentrations which would normally produce lethargy or even coma.

Alcohol withdrawal symptoms MINOR WITHDRAWAL SYMPTOMS  Insomnia Tremulousness Mild anxiety Gastrointestinal upset Headache Diaphoresis Palpitations Can treat in the outpatient setting

Alcohol Withdrawal Gamma aminibutyric acid GABA

ETOH Withdrawal and timeline -seizures occur predominantly in patients with a long history of chronic alcoholism. Can show up from 2 hours and when patient still has ETOH level -Alcoholic hallucinosis refers to hallucinations that develop within 12 to 24 hours of abstinence and resolve within 24 to 48 hours . - Hallucinations are usually visual, although auditory and tactile phenomena may also occur. In contrast to delirium tremens, alcoholic hallucinosis is not associated with global clouding of the sensorium, but with specific hallucinations, and vital signs are usually normal

Delirium Tremens Defined as: Hallucinations, disorientation, altered mental status, tachycardia, hypertension, fever, agitation, and diaphoresis Can start from 48-96 hours from last drink Could last from 1-7 days Mortality of 5% -Death usually is due to arrhythmia, complicating illnesses, such as pneumonia, or failure to identify an underlying problem that led to the cessation of alcohol use, such as pancreatitis, hepatitis, or central nervous system injury or infection. Older age, preexisting pulmonary disease, core body temperature greater than 40ºC (104ºF), and coexisting liver disease are associated with a greater risk of mortality

Risk factors for Delirium Tremens History of DT Age > 30 Longer period of drinking Multiple medical illness Significant alcohol withdrawal despite high ETOH level A longer period since the last drink

Management of ETOH Withdrawal Alleviating symptoms of psychomotor agitation Volume deficit replacement: Hypovolemic Correcting metabolic derangements Electrolyte imbalance : Potassium, Magnesium , Phosphorous Ketoacidosis Vitamin deficiencies: Wernicke’s encephalopathy. Give Thiamine with glucose. Protein calorie malnutrition Hypovolemic: diaphoresis, hyperthermia, vomiting, and tachypnea Hypokalemia is common due to renal and extrarenal losses, alterations in aldosterone levels, and changes in potassium distribution across the cell membrane Hypomagnesemia is common in patients with DT and may predispose to dysrhythmia and seizures Hypophosphatemia may occur due to malnutrition, may be symptomatic, and if severe, may contribute to cardiac failure and rhabdomyolysis

Supportive care GI absorption can be impaired so using IV in the first 2 days is helpful Banana bag: D5NS with thiamine, folate, and a multivitamin If intoxicated and severe withdrawal consider NPO initially to avoid aspiration

Treatment of psychomotor agitation CIWA- Ar Nausea/Vomiting (0-7) Headache(0-7) Paroxysmal sweating (0-7) Anxiety (0-7) Auditory disturbances (0-7) Visual disturbances (0-7) Agitation (0-7) Tremor (0-7) Tactile Disturbances (0-7) Orientation and clouding of sensorium (0-4)

CIWA-Ar Symptom triggered therapy Start treatment at CIWA score > 8 < 10 : Very Mild withdrawal 10-15: Mild withdrawal 16-20: Modest withdrawal >20 : severe withdrawal Start treatment at CIWA score > 8 Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWAS-Ar), a measure of withdrawal severity

Benzodiazepines Diazepam (Valium) 5-10 mg IV every 5-10min Lorazepam (Ativan ) 2-4 mg IV every 10-20 min Chlordiazepoxide (Librium) (should be used in PPX) Should be given IV in modest-severe withdrawal Dosing: depends on comorbid conditions Diazepam: longer acting with active matobolites Lorazepam: shorter acting better with liver disease Librium should be avoided in all cirrhotic patients

Prophylaxis Consider PPX in asymptomatic patients who have high risk factors for DT and withdrawal. Librium taper: 50 to 100 mg POq6hrs for one day and then 25 to 50 mg Q6hrs for 2 days. Can use Librium for very mild withdrawal in low risk patient 25-50 mg PO as needed Q1hrs.

Other treatments Ethanol Antipsychotics (such as Haldol) Anticonvulsants ( such as phenobarbital, Carbamazepine) Centrally acting alpha-2 (Such as Clonidine) Beta blockers (Such as Propranolol) Baclofen These agents are less well studied than benzodiazepines and may mask the hemodynamic signs of withdrawal, which can precede seizures. Ethanol: difficult to titrate Haldol: decreases seizure threshold . Plus prolong QT given all the electrolyte abnormalities Phenobarb can be used in conjunction with benzos in ICU setting but not alone Carbamazepine can sometimes be used in mild but not in inpatient settting Clonidine no evidence that helps reduce DT or seizures. Not enough evidence Beta blocker is the same as alpha Baclofen does bind to GABA but no evidence of controlling severe symptoms

ICU admission

Opioid Withdrawal Sign and symptoms can start within 6-12 hour after short acting opioid and 24-48 hrs after Methadone History can help you diagnose. Severity of symptoms depends of duration, dose of opioid and if there is a iatrogenic withdrawal

Opioid withdrawal Natural opioid withdrawal is not life threating Iatrogenic withdrawal can be dangerous: reversal agent such as Naloxone or naltrexone can produce sudden surges in catecholamines and hemodynamic instability

Opioid withdrawal

Opioid withdrawal Opioid agonist therapy: if they missed a dose or two Methadone 10 mg IM or Methadone 20 mg PO if they can tolerate PO

Opioid withdrawal Non-opioid adjunctive medications Alpha 2 antagonist Clonidine: 0.1 to 0.3 mg every hour as needed Benzodiazepine: Diazepam 10-20 mg IV q5-15min PRN Phenegran: 25 mg IV or PO Loperamide Octerotide - Binds to a central alpha 2 adrenergic receptor that shares potassium channels with opioids, and blunts symptoms of withdrawal. Look for hypotension -Benzos: GABAergic drugs reduce catecholamine release during severe withdrawal. helpful in suppressing muscle cramps. -