1. Alcohol Detoxification
Dr Julia Lewis
GSSMS

2. Overview What is alcohol withdrawal?
How is alcohol withdrawal treated?
Importance of vitamins
Details of Symptom Triggered Detoxification
Gwent treatment agencies

3. The Alcohol Withdrawal Syndrome
a question….
What experiences have you had of patients undergoing alcohol withdrawal/ detoxification?

4. Alcohol Withdrawal
Develop 6-8 hours after last drink
Maximal in first 24 hours
Risk of seizures low after 48 hours
Typically over by 5 days 6
Hrs 24
Hrs 48
Hrs 5
Days

5. Visual/ tactile hallucination
Alcohol Withdrawal Symptoms: the slippery slope
Anxiety
Tremors
Sweats
Confusion
Fever
Tachycardia
Visual/ tactile hallucination
Seizures
Death

6. Uncomfortable withdrawal Seizures / autonomic instability and death
Alcohol Withdrawal
Mild withdrawal
Uncomfortable withdrawal
DTs / Wernicke’s
Seizures / autonomic instability and death

7. The brain likes the system to remain in balance
Basic Neurobiology
CNS contains balance of excitatory and inhibitory neurotransmitters
Excitatory
Inhibitory
The brain likes the system to remain in balance

8. Cell Body Neurophysiology Insulation Insulation
Vesicle containing inhibitory neurotransmitter
Vesicle containing excitatory neurotransmitter
Excitatory receptor
Inhibitory receptor

9. GABAA Receptor
Cl-

10. Kindling no alcohol full blown DT’s with hallucinations & delusions
spontaneous seizures
seizures
anxiety, panic, agitation
autonomic symptoms
(sweating, tachycardia)
shakes, tremors 5 10 15 17 19 21 23 25
no alcohol
Estimated number of alcohol withdrawal episodes

11. Glutamate & GABA
Glutamate
excitatory
GABA
inhibitory

12. Neuro-adapation: Rabbits & Donkeys+
glutamate -
GABA

13. Neuro-adapation: Rabbits & Donkeys+
glutamate -
GABA

14. Neuro-adapation: Rabbits & Donkeys+
glutamate -
GABA

15. Neuro-adapation: Rabbits & Donkeys+
glutamate -
GABA

16. The Pesky Glutamate Glutamate has a neurotoxic effect (excitotoxicity)
When glutamate builds up in the synaptic gap and the brain can’t clear it – it kills itself!
Potential protective effect with acamprosate

17. How do we do alcohol detoxification?

18. Neuro-adapation: Rabbits & Donkeys
So detox is: =
Benzodiazepine

19. How might a patient feel coming in for a detox?

20. Pharmacological Management
Alcohol Detoxification
Pharmacological Management
Supportive Nursing
of equal importance
Reality orientation
Minimise stimulation, calm environment
Nutrition & hydration

21. Pharmacotherapy Drugs with cross-tolerance with alcohol
(reviewed by Williams and McBride, 1998)
Benzodiazepines are preferred (diazepam, chlordiazepoxide)

22. Fixed Reduction
Frequent small doses of a BZD tapering over a period of 5-7 days
Problems:
over medication
under medication (kindling)
drug seeking behaviour

23. Fixed Reduction: when it is useful
Wards not trained to use Front-Loading
In special groups where hepatic function is reduced and shorter acting benzodiazepines are required (e.g. the elderly, hepatic impairment)
What are the shorter acting benzodiazepines? – oxazepam, lorazepam

24. Fixed Reduction:schedule
Day
Morning
Lunch
Afternoon
Night 1
20mg
High Start 2
15mg
Medium 3
Low Start 4
10mg 5 6 7

25. Very Severe Dependence Daily Alcohol Consumption
Fixed Reduction: where to start
Moderate Dependence
Severe Dependence
Very Severe Dependence
Daily Alcohol Consumption
15-29 units
30-40 units
50-60 units
SADQ Score
15-30
30-40
40-60
Detox Start
Low
Medium
High

26. Fixed Reduction: additional notes
PRN diazepam (5-20mg doses; max of 150mg total dose daily) – can be given at 2 hourly intervals but not usually given after first 48 hours. May need to alter timing of regular doses.
Doses are not absolute and can be increased or decreased according to withdrawal severity
Omit doses if patient drowsy

27. Front Loading / Symptom Triggered Therapy
Aims
To match pharmacotherapy to withdrawal symptoms
To prevent kindling by (more-or-less) completely eradicating symptoms

28. STT: basic technique
Patient assessed at appropriate intervals (90 mins)
Standardised assessment tool used (CIWA-Ar)
Those scoring above threshold given appropriate medication (20mg diazepam if scoring 11 or above)

29. STT: Diazepam Ideally suited because of pharmacokinetics
Rapidly absorbed
T1/2 diazepam = 33 +/- 11 hours
T1/2 desmethyldiazepam = 50 hours
Active metabolites present longer than the 72 hrs of AWS (Sellers et al, 1983)

30. STT: research Effective – good completion rates
Studies have shown similar completion rates to other techniques
(Wiseman et al, 1998)

31. STT: research Safe – no major complications
7 studies between had no major complications (n=327)
In one study minor complaints such as muscle weakness and drowsiness were described but no pt discontinued.
In a comparison study, one pt in both STT and FR groups had DTs
(Sellers et al, 1983; Heinala et al, 1990; Wartenburg et al, 1990; Saitz et al, 1994; Salloum et al, 1995; Wasilewski et al, 1996; Wiseman et al, 1998)

32. Lower doses of benzodiazepines used in total
STT: research
Lower doses of benzodiazepines used in total
Chlordiazepoxide
Satis et al, 1994
STT - 100mg
FR - 425mg
Study 1
Diazepam
Wasilewski et al,
1996
STT mg
FR mg
Study 2
Diazepam
Day et al, 2004
STT - 74mg
FR - 250mg
Study 3

33. STT: research Shorter period of detoxification
Wartenburg et al (1990) – 5 hours for STT cf 13 hours for FR
Sullivan et al (1991) – the ‘typical’ patient requires only 2 – 3 doses of 20mg diazepam or 100mg CDP

34. STT: research STT can be used for home detox
Currently used by Home Alcohol Detoxification Service in Torfaen (and in other areas)
Has been shown to be safe and effective in this format (Blondell, 2005)

35. STT: cautions When to start?
Other causes of autonomic and psychomotor agitation
Clonidine and beta-blockers
Sleep vs coma – once asleep continue to check at 90min intervals but check resp rate. Score once more upon waking.

36. Diazepam: too much? Death Respiratory Suppression Drowsiness Shakes
Sweats
Hallucinations
Seizures
Too much GABA Stimulation
Too little GABA Stimulation

37. Nursing Reassurance can reduce need for diazepam
Maintain calm environment
Reduce level of stimulation
Consistency of personnel
Avoid carbohydrate load

38. Vitamin Prophylaxisis

39. Thiamine Co-enzyme in carbohydrate metabolism
2 routes absorption – active and passive
Alcohol problems lead to poor diet
Alcohol impairs active absorption
Wernicke/ Korsakoff
Withdrawal is time of increased risk

40. Glutamate overactivity Diet low in thiamine
Chronic Drinking
Withdrawal
Glutamate overactivity
Diet low in thiamine
Poor absorption of thiamine
Increased demand for energy
Low body stores of thiamine
Carbohydrate metabolism
Brain damage
Carbohydrate metabolism
Limited repair
Use of thiamine

41. Wernickes Encephalopathy
Confusion
Ophthalmoplegia (eye muscles not working properly)
Nystagmus
Truncal ataxia (unsteady gait)
High index of suspicion – mortality rate 17-20% and 85% develop Korsakoffs

42. Korsakoff’s Psychosis
Chronic memory loss (new memories)
Apathy – can be profound
Some loss of old memories – may stretch back many years
Confabulation – fabrication of memories; generally displaced; may be fantastical
Often orientated to place but take long time to adapt to new surroundings

43. Hepatic encephalopathy Central Pontine Myelinolysis
All part of ARBD
Brain Injury
Vascular diseases
Direct trauma
Korsakoff’s
Syndrome
Also acute
syndrome of
Wernicke’s
Neurological
Syndromes
Cerebellar atrophy
Hepatic encephalopathy
Central Pontine Myelinolysis
Marchiofava Bignami Syndrome
Alcohol
Related
Dementia
Subcortical
frontal disorders

44. Thiamine: part 2 Prophylaxis during withdrawal
2 amps daily for 5 days (im or iv)
Treatment of Wernickes
2 amps bd
Risk of anaphylaxis is small but real – resuscitation facilities required (1 report for every 5 million doses sold (CSM) – underestimate?)

45. Delirium Tremens Confusion, disorientation, agitation
Autonomic instability (raised temp, HR, BP)
Hallucinations (visual, tactile)
Tremors
Paranoia
In 5-10% alcohol dependent patients
Up to 5% mortality if treated; 35% if not

46. Using the CIWA-Ar
Clinical Institute Withdrawal Assessment for Alcohol (revised)
(Sullivan, 1991)
Objective assessment of withdrawal
Assess at 90 minute intervals
Stop after two scores below 11

47. CIWA-Ar: Basic Information Name Date Time
BP, HR, temp - don’t contribute to score but can give early signs of complications

48. CIWA-Ar: Nausea & Vomiting Score Indication No nausea and no vomiting
No nausea and no vomiting 1
Mild nausea with no vomiting 2 3 4
Intermittent nausea with dry heaves 5 6 7
Constant nausea, frequent dry heaves and vomiting

49. CIWA-Ar: Tremor Score Indication No tremor 1
No tremor 1
Not visible, but can be felt fingertip to fingertip 2 3 4
Moderate, with patients arms extended 5 6 7
Severe, even with arms not extended

50. CIWA-Ar: Sweats Score Indication No sweat visible 1
No sweat visible 1
Barely perceptible sweating, palms moist 2 3 4
Beads of sweat obvious on forehead 5 6 7
Drenching sweats

51. CIWA-Ar: Anxiety Score Indication No anxiety, at ease 1 Mildly anxious
No anxiety, at ease 1
Mildly anxious 2 3 4
Moderately anxious, or guarded, so anxiety is inferred 5 6 7
Equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions

52. CIWA-Ar: Agitation Score Indication Normal activity 1
Normal activity 1
Somewhat more than normal activity 2 3 4
Moderately fidgety and restless 5 6 7
Paces back and forth during most of the interview, or constantly thrashes out

53. CIWA-Ar: Tactile Disturbances Score Indication None 1
None 1
Very mild itching, pins & needles, burning or numbness 2
Mild itching, pins & needles, burning or numbness 3
Moderate itching, pins & needles, burning or numbness 4
Moderately severe hallucinations 5
Severe hallucinations 6
Extremely hallucinations 7
Continuous hallucinations

54. CIWA-Ar: Auditory Disturbances Score Indication Not present 1
Not present 1
Very mild harshness or ability to frighten 2
Mild harshness or ability to frighten 3
Moderate harshness or ability to frighten 4
Moderately severe hallucinations 5
Severe hallucinations 6
Extremely hallucinations 7
Continuous hallucinations

55. CIWA-Ar: Visual Disturbances Score Indication Not present 1
Not present 1
Very mild sensitivity 2
Mild sensitivity 3
Moderate sensitivity 4
Moderately severe hallucinations 5
Severe hallucinations 6
Extremely hallucinations 7
Continuous hallucinations

56. CIWA-Ar: Headache Score Indication Not present 1 Very 2 Mild 3
Not present 1
Very 2
Mild 3
Moderate 4
Moderately 5
Severe 6
Very severe 7
Extremely severe

57. CIWA-Ar: Orientation Score Indication Orientated 1
Orientated 1
Cannot do serial additions or is uncertain about date 2
Disorientated for date by no more than 2 calendar days 3
Disorientated for date more than 2 calendar days 4
Disorientated for place/ or person

58. CIWA-Ar:
Practice Time

59. Summary
Symptom Triggered detox is safe and effective and helps prevent kindling
Thiamine replacement is important
The nursing component to withdrawal is probably the most important