Management of Acute Alcohol Opiate Withdrawal

1. Management of AcuteAlcohol & Opiate Withdrawal Todd A. May, M.D. Director, Family Medicine Inpatient Service San Francisco General Hospital Clinical Professor Department of Family & Community Medicine University of California, San Francisco

2. Goals Review manifestations of withdrawal syndromes Assess risk and severity of w/d Strategies to optimize therapy Review SFGH Guidelines

3. Challenges of AWS Management Under-treatment ? Use of restraints, dangerous situations Progression to DTs, higher mortality Over-treatment Benzodiazepine intoxication, delirium Sedation, aspiration, intubation Inappropriate BZD choice and dosing Wrong diagnosis or missed co-morbid condition

4. Alcohol Withdrawal Syndrome Symptoms anxiety insomnia tremulousness headache nausea Signs tremor diaphoresis agitation tachycardia hypertension low grade fever (<38.5)

5. Withdrawal Seizures Generalized, non-focal Seizure onset < 48 hours after cessation May recur; status epilepticus rare Look for other etiology if: onset > 48 hours focal seizures fever or head trauma

6. Alcohol Hallucinosis Early onset�12 to 24 hours after cessation Able to maintain clear sensorium Resolves in 24 to 48 hours

7. Alcohol Withdrawal Delirium (DTs) Onset 48 - 96 hours after cessation Usually following prolonged, heavy drinking Clouding of consciousness Delirium

8. Alcohol Withdrawal Delirium (DTs) Delirium impaired attention/concentration disorientation waxing/waning level of consciousness hallucinations � visual > tactile >> auditory delusions

9. If delirium persists or atypical features, consider: Infection CNS event (e.g., subdural hematoma) Metabolic disturbance Hepatic encephalopathy Wernicke�s encephalopathy BZD intoxication Psychiatric disorder Alcohol Withdrawal Delirium (DTs)

11. Assessing Risk of AWS Frequency, amount, time of last drink H/O w/d; needing meds for detox H/O seizures, hallucinosis, or DTs Concurrent substance use Comorbid illness

12. Assessing Risk of AWS Prior w/d history is strongest predictor Mild risk self-limited w/d symptoms Moderate risk w/d requiring medications Severe risk w/d seizure or delirium

14. CIWA-Ar Nausea, vomiting Tremor Sweats Anxiety Agitation Tactile disturbance Auditory disturbance Visual disturbance Headache Orientation/clouding of sensorium

15. CIWA Developed, studied extensively 1980s Originally 18 items ? 10 Imported to various settings Detox units Psychiatric units Medical-surgical wards

16. CIWA CIWA score predicts (in detox units) Severe w/d symptoms, seizures, delirium Naranjo Clin Pharm Therap 1983;34:214-19 Hospitalized medical patients CIWA > 15 predicts severe w/d and delirium RR 3.72 (95% CI 2.85-4.85) Foy Alc Clin Exp Res 1988;12:360-64

17. Assessing Severity of AWS Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar) Reliable, validated assessment tool Brief, easy to use Score correlates with severity of w/d Enhances communication between staff Can guide management decisions Recommended by ASAM

18. CIWA-Ar Caveats Not diagnostic Assessment tool only Must interpret score in clinical context Co-morbid illness can confound the scoring Bottom line: Interpret--don�t just treat a number Work together with the nurses

19. CIWA-Ar Score 8-15 Mild Score 16-25 Moderate Score > 25 Severe

21. Management of AWS General Measures Seizure precautions with h/o Sz Hydration Thiamine 100mg IM/IV prior to glucose Correct electrolytes�Mg, Ca, K, PO4 Treat concurrent illnesses

22. Management of AWS Which drug? What route? How to dose?

23. Management of AWS Benzodiazepines (BDZ) Treatment of choice Clearly reduce symptoms and ? risk of Sz (-4.9/100 pt), delirium (-7.7/100 pt) Phenobarbital Narrow therapeutic index Carbamazepine Effective alternative, less sedation

24. Choice of Benzodiazepine All seem effective for AWS Limited comparative data All metabolized by liver Differences Onset of action, half life, routes 1 or 2 step metabolism; active metabolites Long vs shorter acting

25. Long-acting BDZs Chlordiazepoxide (Librium�) Oral dosing only Intermediate onset Long-acting parent compound and metabolites Smoother withdrawal, less sz, better cognitive fxn Potential accumulation in elderly and patients with liver disease [Diazepam]

26. Shorter-acting BDZs Lorazepam (Ativan�) Versatile dosing�PO, IV, IM, SL Fast to intermediate onset Intermediate half-life, no metabolites Less likely to accumulate in elderly or with liver disease Breakthrough sx, met. acidosis, delirium [Oxazepam]

27. Benzodiazepines Chlordiazepoxide generally preferred Indications for Lorazepam Elderly Established liver disease NPO Severe w/d requiring frequent or high doses

28. Benzodiazepines Route of administration Oral preferable Ease of administration More consistent blood levels Sublingual if NPO (e.g., surgical patients) Intravenous Severe w/d requiring rapid titration or NPO

29. Benzodiazepines--Dosing Options �Fixed Schedule� Regimens Traditional approach Administer BZD around the clock Additional doses prn Taper by 25% per day when stable Risk for under-dosing, over-sedation, drug accumulation

30. Benzodiazepines--Dosing Options

32. Symptom-triggered vs. fixed dose

33. Symptom-triggered therapy 101 patients, VA inpatient detox center Randomized, double-blind STT vs fixed dose schedule with chlordiazepoxide Results Lower total BDZ: 100mg vs 425mg (p<0.01) Shorter duration: 9h vs 68hr (p<0.01) Trend: ? severity, Sz, DTs

34. Symptom-triggered therapy 216 Medical inpatients Retrospective, pre-/post-intervention Results *Delirium: 21 ? 7% (p=0.04)* Total BDZ equiv: 20 ? 20 (p=0.38) Duration: 56hr ? 45hr (p=0.16) Complications: 33 ? 18% (NS) Mortality: 2.4% ? 0 (NS)

35. Symptom-triggered therapy Medical inpatients No RCTs of STT vs. fixed dosing (no RCTs for fixed dosing either) Many observational and retrospective studies with a variety of BDZ General: STT as effective or better Variable ? severity, LOS, total med, DTs, etc Makes sense; Growing trend worldwide; Beware of pitfalls and limitations

36. SFGH Guidelines Three Clinical Scenarios Risk, but no active w/d Mild-moderate w/d Severe w/d 3 Pre-printed order forms

37. Risk for Withdrawal (CIWA <8) Observation only No prior h/o w/d or not actively drinking Severe or decompensated liver disease Order: CIWA q 6hr, call HO > 8 Prophylaxis Use only if h/o w/d Select drug based on patient profile Select dosing taper based on severity of hx

38. Mild-Mod Withdrawal (CIWA 8-25) Symptom-triggered therapy Select drug based on patient profile �Sliding scale� STT strategy Select drug, not dose Reassess periodically for adequacy of symptom control or over-sedation

39. Mild-Mod Withdrawal (CIWA 8-25)

40. Severe Withdrawal (CIWA>25) Urgent, serious, unstable situation Abandon CIWA; goal sedation score of 3 Lorazepam IV bolus q15-30min prn Haloperidol for agitation when autonomic symptoms controlled Avoid Lorazepam infusion if possible Infusion management tips

41. AWS Summary Become familiar with CIWA scale Assess risk for w/d Choose BDZ based on pt profile Symptom-triggered therapy, usually Individualize treatment, reassess Minimize IV drips Adjunctive Haloperidol for delirium

42. Opiate Withdrawal Very uncomfortable Not life-threatening, in contrast to alcohol withdrawal Concurrent medical problems and medications can complicate treatment

43. Opiate Withdrawal Symptoms Anxiety Insomnia Abd pain/cramps Rhinorrhea Lacrimation Yawning N/V/D Signs Dilated pupils Diaphoresis Piloerection No seizures, tremor, DTs

44. Opiate Withdrawal W/D Heroin Methadone Onset 12-24hr 1-3d Peak 2-3d 5-7d Duration 5-7d 14-21d

46. Methadone Treatment On methadone maintenance Confirm outpatient dose with clinic Continue outpatient dose Do not split dose or increase to treat pain

47. Methadone Treatment--Initial Not on methadone; dose unconfirmed Give 10-20mg once Evaluate in 4-8hr for sedation or persistent w/d signs, symptoms Give additional 10-20mg if needed Usually need =40-60mg/24h Order adjunctive medications

48. Methadone Treatment--subsequent Evaluate for w/d daily If w/d present and no sedation, may increase daily dose by 10-20mg Must evaluate for sedation 4-8hr after dose increase Taper by ~5mg/d, as tolerated, when symptoms controlled

49. Alternative/Adjunctive Treatment Clonidine Non-opioid treatment of noradrenergic-activated neuronal activity Decreases severity of w/d symptoms Acutely titrate to symptoms, taper after day 3 Clonidine 0.1mg q4h prn symptoms (write BP parameter)

50. Adjunctive Treatment Helpful in safely controlling symptoms Hydroxyzine 25-50mg q6h prn anxiety/insomnia Ibuprofen 400-800mg q6h prn pain Trazadone 50-100mg bedtime prn insomnia Loperamide ii tab (2mg ea) initially, then i tab prn diarrhea, NTE 16mg/d

51. Pain Management & Methadone Once daily methadone for opiate dependence�dispensed by licensed clinics only Divided dose can be used for chronic pain Patients on methadone with acute pain: Continue outpt methadone dosing Prevent opiate w/d Avoid substantial change in outpt regimen Choose alternative opioid for acute pain control

52. Methadone Do NOT: Split usual once daily methadone dose Give initial (unconfirmed) dose >30mg Use methadone for both opiate dependence and pain control Write prn orders for methadone

53. Methadone: drug interactions Increase metabolism (?methadone effect) Phenytoin, carbamazepine Protease inhibitors, Efavirenz, Nevirapine Rifampin Decrease metabolism (? effect) Benzodiazepines Quinolones

54. Discharge Planning Assess patient�s interest in long-term Rx early (plan ahead) Patient�s options: Continue drug use Short-course detox while hospitalized 30d detox or methadone maintenance at Ward 93 Plan inpatient management accordingly Don�t Rx with constant dose and d/c without plan

55. Buprenorphine Opioid agonist and partial antagonist Can be prescribed in office practice Cannot be started at SFGH while inpatient Patients admitted on maintenance Continue confirmed outpatient dose Mild-mod pain: NSAIDs, codeine, hydrocodone Severe pain: stop buprenorphine, use morphine or other potent narcotic analgesic See CHN guidelines; Pain Management consult recommended

56. Todd May Office: 4F43 Phone: 206-5786 Pager: 443-9702