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Managing Alcohol and Opioid Withdrawals

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

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  1. Managing Alcohol and Opioid Withdrawals PounehNasseri MD Chief resident

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

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

  4. 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

  5. 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

  6. 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).

  7. Alcohol withdrawal symptoms • MINOR WITHDRAWAL SYMPTOMS  • Insomnia • Tremulousness • Mild anxiety • Gastrointestinal upset • Headache • Diaphoresis • Palpitations

  8. Alcohol Withdrawal

  9. ETOH Withdrawal and timeline

  10. 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%

  11. 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

  12. 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

  13. 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

  14. 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)

  15. 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

  16. 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

  17. 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.

  18. 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

  19. ICU admission

  20. 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

  21. 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

  22. Opioid withdrawal

  23. 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

  24. 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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