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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.

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Managing alcohol and opioid withdrawals

Managing Alcohol and Opioid Withdrawals

PounehNasseri MD

Chief resident


Goals of lecture
Goals of lecture

  • Recognize alcohol and opioid withdrawal in the inpatient setting

  • Management of withdrawal in the inpatient setting


Alcohol use terminology
Alcohol use terminology

Standard drink Approximate # of standard drinks in:

Equivalents:


Recognizing alcoholism
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


How many drinks are too many
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


Alcohol w ithdrawal pathophysiology
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).


Alcohol withdrawal symptoms
Alcohol withdrawal symptoms

  • MINOR WITHDRAWAL SYMPTOMS 

    • Insomnia

    • Tremulousness

    • Mild anxiety

    • Gastrointestinal upset

    • Headache

    • Diaphoresis

    • Palpitations




Delirium tremens
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%


Risk factors for delirium tremens
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
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


Supportive care
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
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
CIWA-Ar

  • Symptom triggered therapy

    • < 10 : Very Mild withdrawal

    • 10-15: Mild withdrawal

    • 16-20: Modest withdrawal

    • >20 : severe withdrawal

  • Start treatment at CIWA score > 8


Benzodiazepines
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


Prophylaxis
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
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



Opioid w ithdrawal
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
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 withdrawal2
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 withdrawal3
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


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