Keri Holmes-Maybank, MD Cathryn Caton, MD, MS MUSC June 21, 2012 Alcohol Withdrawal Keri Holmes-Maybank, MD Cathryn Caton, MD, MS MUSC June 21, 2012

Objectives Define Dependence Define Withdrawal Describe symptoms and stages of withdrawal Describe goals of therapy Review management of withdrawal Pharmacological and non-pharmacological interventions

Alcohol Dependence DSM-IV Diagnostic Criteria A maladaptive pattern of alcohol use, leading to clinically significant impairment or distress, as manifested by three or more of the following seven criteria, occurring at any time in the same 12-month period: 1. Tolerance, as defined by either of the following: a) A need for markedly increased amounts of alcohol to achieve intoxication or desired effect. b) Markedly diminished effect with continued use of the same amount of alcohol. 2. Withdrawal, as defined by either of the following: a) The characteristic withdrawal syndrome for alcohol (refer to DSM-IV for further details). b) Alcohol is taken to relieve or avoid withdrawal symptoms. 3. Alcohol is often taken in larger amounts or over a longer period than was intended. 4. There is a persistent desire or there are unsuccessful efforts to cut down or control alcohol use. 5. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol or recover from its effects. 6. Important social, occupational, or recreational activities are given up or reduced because of alcohol use. 7. Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the alcohol (e.g., continued drinking despite recognition that an ulcer was made worse by alcohol consumption).

Alcohol Withdrawal DSM IV Criteria A. Cessation of (or reduction in) alcohol use that has been heavy and prolonged. B. Two (or more) of the following, developing within several hours to a few days after Criterion A: (1) autonomic hyperactivity (e.g., sweating or pulse rate greater than 100) (2) increased hand tremor (3) insomnia (4) nausea or vomiting (5) transient visual, tactile, or auditory hallucinations or illusions (6) psychomotor agitation (7) anxiety (8) grand mal seizures C. The symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The symptoms are not due to a general medical condition and are not better accounted for by another mental disorder. Specify if: With Perceptual Disturbances

Kindling Intensity of withdrawal symptoms increases with successive episodes of withdrawal

3 Stages of Withdrawal Stage 1 Stage 2 Stage 3 Minor Major Delirium tremens

Minor Symptoms Appear between 6 and 48 hours after heavy alcohol consumption decreases May occur with significant alcohol blood levels Initial symptoms intensify and then diminish over 24 to 48 hours Headache Tremor Diaphoresis Anxiety and irritability Nausea and vomiting Heightened sensitivity to light and sound Insomnia

Alcoholic Hallucinosis NOT delirium tremens Occur within 12-24 hours of cessation Resolve within 24-48 hours Specific hallucinations Usually visual No globally clouded sensorium Vital signs normal

Delirium Tremens Most intense and serious syndrome ~ 5% of patients, 5% mortality rate Occurs 48-96 hours after cessation May last 5 days Severe agitation Tremor Disorientation Persistent hallucinations Fever Tachycardia Tachypnea Hypertension Diaphoresis

Risk Factors for DT’s History of sustained drinking History of previous DT’s >30 years old Concurrent illnesses (psych or medical) Significant withdrawal symptoms with elevated BAL Prolonged interval between cessation and presentation to health care professional

Alcohol Withdrawal Seizures Occur in up to 25% of withdrawal episodes Generalized tonic-clonic convulsions Usually occur 12-48 hours after last drink More common after years of drinking

Goals of Therapy Reduce severity of withdrawal symptoms Prevent seizures Prevent DT’s Reduce morbidity and mortality associated with severe alcohol withdrawal

Indications for Outpatient Treatment No specific criteria Mild to moderate symptoms (Stage 1-2) No medical or psychiatric conditions that may complicate withdrawal No prior h/o AW seizures or DT’s Sober support person CIWA-Ar score <15 Able to take po meds Not psychotic, suicidal or significantly cognitively impaired No concurrent substance abuse problems

Indications for Inpatient Treatment History of Severe withdrawal symptoms Alcohol withdrawal seizures Delirium tremens Multiple past detoxifications Concomitant medical or psychiatric illness Recent high levels of alcohol consumption Lack of reliable support network Pregnancy

Admission Blood alcohol level EKG BMP, magnesium, phosphorus CDT % CIWA-A, modified

Nonpharmacological Management Mild withdrawal symptoms (Stage 1) Supportive care Quiet environment, well-lit Limited interpersonal interaction Nutrition Fluids Reassurance and encouragement Reorientation – calendars, clocks

Pharmacological Management Moderate to severe withdrawal (Stage 2-3) Clinicians disagree on the optimum medications and prescribing schedules Sedative hypnotic drugs are recommended as the primary agents for managing DT’s(grade A recommendation). Benzodiazepines are the treatment of choice based on two major reviews Reduce occurrence of seizures and delirium Reduce severity of withdrawal symptoms

Benzodiazepines Act on GABA-A receptors, similarly to alcohol CIWA-A, modified - symptom triggered short acting lorazepam Many clinicians prefer long acting diazepam or clonazepam to avoid symptoms and/or worsening of symptoms Avoid use of long-acting benzos in elderly or liver disease

Benzodiazepines – Short vs. Long Acting Agents with rapid onset control agitation more quickly, for example, oral or IV diazepam has a more rapid onset than other agents (level II evidence) Agents with long duration of action (eg, diazepam) provide a smooth treatment course with less breakthrough symptoms Agents with shorter duration of activity (eg, lorazepam) may have lower risk when there is concern about prolonged sedation, such as in patients who are elderly or who have substantial liver disease or other serious concomitant medical illness (level III evidence) The cost of different benzodiazepines can vary considerably.

Benzodiazepines – Symptom Triggered vs. Scheduled Symptom triggered is as effective as fixed dose therapy Requires significantly less benzodiazepines Leads to a more rapid detoxification However, patients with a CIWA score of 15 or history of withdrawal seizures need scheduled benzos

CIWA-A, modified Clinical Institute Withdrawal Assessment for Alcohol Scale Measures severity of withdrawal Symptom-triggered therapy Objectively quantify severity of withdrawal Well documented reliability, reproducibility, and validity High scores associated with alcohol withdrawal seizures and DT’s Assesses need for medication Assess appropriate site for detox Evaluates status during treatment

CIWA Nausea and vomiting Paroxysmal sweats Anxiety Headache Auditory disturbances Visual disturbances Agitation Tremor Tactile disturbances Orientation and clouding of sensorium

CIWA-A, modified Includes heart rate, temperature, respiratory rate, blood pressure Type A – CNS excitation Anxiety Headache Agitation Type B – Adrenergic Hyperactivity Tremor Nausea and Vomiting Paroxysmal Sweats Heart rate Blood pressure Type C – Delirium Auditory Disturbances Visual Disturbance Tactile disturbances Orientation and clouding of sensorium

Medications for CIWA-A, modified Type A – CNS excitation Lorazepam Type B – Adrenergic Hyperactivity Clonidine Type C – Delirium Haloperidol

Additional Medication Thiamine –***give prior to any glucose*** Folic acid Multivitamin IVF Electrolyte replacement as needed

Gabapentin Recommended by MUSC Psychiatry Conflicting trials for gabapentin 300mg TID x 1 week, 200mg TID x week, 100 mg x week Pro’s Lack of drug-drug interactions Lack of cognitive impairment Lack of abuse potential Renal excretion

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