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Back to basics! Substance abuse/drug addiction/withdrawal

Back to basics! Substance abuse/drug addiction/withdrawal. March 19, 2012 Dr. Gabrielle Cyr PGY-3 resident, psychiatry University of Ottawa. Objectives. Key objectives Determine whether the patient is in need of emergency care because of withdrawal symptoms or other complications

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Back to basics! Substance abuse/drug addiction/withdrawal

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  1. Back to basics!Substance abuse/drug addiction/withdrawal March 19, 2012 Dr. Gabrielle Cyr PGY-3 resident, psychiatry University of Ottawa

  2. Objectives • Key objectives • Determine whether the patient is in need of emergency care because of withdrawal symptoms or other complications • Objectives • Take an efficient/focused addictions history • List/interpret clinical/laboratory findings which are key to the processes of exclusion/differentiation and diagnosis • Conduct and effective initial plan of management for a patient with substance abuse

  3. Why do we care? • Anybody can be affected (++ common) • All specialties of medicine • Major psychosocial/functionnal impacts • Potentially lethal

  4. Basics of addiction • Genetic vulnerability • Environmental factors • Low socioeconomic status • Chaotic background • Etc… • Repeated use

  5. Creating an addiction • Drugs→ activation of the reward system of the brain (mesolimbic dopamine system)→flooding of Dopamine • Repeated use = changes in function • ↓Dopamine/Dopa receptor production→ need ↑amounts of drugs to create pleasure

  6. Substances • Depressants • Alcohol • Benzodiazepines • Barbiturates • Opioids • Stimulants • Amphetamines • Cocaine • Cannabis • Hallucinogens (MDMA, LSD, Psilocybin, Mescaline)

  7. Taking a substance history • Recent (last 6 months-1 year)/past pattern of abuse • Type of substance/route of administration • Quantity/frequency of use/schedule • Severity of use (abuse vs dependence) • Impacts of use • Social/occupationnal/legal (DUI, probation, CAS involvement, etc.) • Medical complications (IV DU, etc.)

  8. Taking a substance history • Family history of substance use • Current/past withdrawal symptoms, severe withdrawal reactions (DT’s, withdrawal seizures, etc.) • Past treatments for addictions • Support system

  9. Physical examination • Cognition/LOC/Orientation • Signs of intoxication (toxidromes)/withdrawal • Vitals • Skin (signs of liver failure, needle marks, etc.) • Pupils • Etc. • +/- complete physical exam

  10. DSM-IV criteria: abuse A. Maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following occurring within a 12 month period: 1. recurrent substance use resulting in a failure to fulfill major obligations at work, school, or home 2. recurrent substance use in situations in which it is physically hazardous 3. recurrent substance-related legal problems 4. continued use despite persistent or recurrent social or interpersonal problems caused by or exacerbated by effects of a substance B. The symptoms have never met the criteria for substance dependence for this class of substance

  11. DSM-IV criteria: dependence • 3 or more occurring over 12 months: • tolerance • withdrawal • larger amounts or longer period of time • unsuccessful efforts to cut down or control • time spent obtaining, using, recovering • activities given up or reduced • continued use despite problems

  12. Standard drinks…

  13. Canada’s low risk alcohol drinking guidelines • No more than: • Women ≤ 10 drinks/week (≤ 2 drinks/day most days) • Men ≤ 15 drinks/week (≤ 3 drinks/day most days) • In one sitting: • Women, no more than 3 drinks • Men, no more than 4 drinks • Plan a few non drinking days/week CCSA, Canada's Low-Risk Alcohol Drinking Guidelines, November 2011

  14. Alcohol - assessment • Always screen; • CAGE questionnaire • Have you ever felt the need to CUT down on your drinking? • Ever felt ANNOYED by criticism of your drinking? • Ever felt GUILTY about your drinking? • Ever had a drink first thing in the morning? (EYE OPENER) • Score 0 or 1 (≥ 2 = significant) • Quick / sensitive 75-85%

  15. Alcohol - assessment • Investigations • LFT’s (GGT, AST:ALT ratio 2:1) • CBC (↑MCV, anemia, thrombocytopenia) • For baseline and monitoring • Potential complications • Cardiac (HTN, cardiomyopathy) • GI (GI tract cancers, gastritis, bleeds) • Neuro (Wernicke-Korsakoff)

  16. Potentially deadly withdrawals… • Alcohol • Benzodiazepines/Barbiturates • GHB…

  17. Alcohol/Benzodiazepine withdrawal • Autonomic hyperactivity (e.g. sweating or pulse rate greater than 100), also labile BP • Increased hand tremor • Insomnia • Nausea or vomiting • Transient visual, tactile, or auditory hallucinations or illusions • Psychomotor agitation • Anxiety • Grand mal seizures • Withdrawal seizures: 6-48 hrs • DT’s: up to 24-72 hrs

  18. Stages of change

  19. Alcohol/benzo withdrawal management • Have to follow motivation for change • Stages of change • Motivationnal interviewing • Outpatient management: • Mild-moderate problem (set drinking goals) • No history of severe withdrawal • Good support/regular follow-up • AA

  20. Community outpatient treatment (Ottawa) • The Royal Substance Use and Concurrent Disorders Program • Sandy Hill Addictions and Mental Health • Rideauwood Addiction and Family Services • Amethyst Women’s Centre • Serenity Renewal for Families • LESA (Lifestyle Enrichment for Senior Adults) • CMHA

  21. Alcohol/benzo withdrawal management • Non medical detoxification/residential treatment • Patient intoxicated/mild withdrawal • Can take own medication • Medically stable • Short stay only

  22. Residential treatment (Ottawa) • Empathy House • Serenity House • Sobriety House • VESTA • Maison Fraternité • The ROMHC Meadow Creek

  23. Alcohol/benzo withdrawal management • Medically supervised detoxification (inpatient) • Severe alcohol/benzodiazepine withdrawal • Delirium tremens • Alcohol withdrawal seizures • Past history/current • Polysubstance use and medical comorbidities (severe CAD, etc.), high dose benzos • Pregnancy

  24. Alcohol/benzo withdrawal management • Inpatient treatment/medical detox • Front loading • High doses, early in withdrawal state • Diazepam 10-20mg q 1-2h for CIWA ≥10, goal is CIWA ≤ 8/sedation • Useful in ER • Fixed dosing • Diazepam/Lorazepam QID with PRN doses q2-4h • Useful if past history DT’s/seizures

  25. Alcohol/benzo withdrawal management • Be careful! • For ALL patients • Thiamine 100mg IM for 3 days, then PO (up to 2 months) • Lorazepam safer if hepatic function unknown

  26. Alcohol addiction treatment • Disulfiram (Antabuse) • Blockade of Aldehyde dehydrogenase • Flushing/nausea+vomiting/hypotension on ingestion of alcohol • Aversive agent • Mild LFT elevation, risk of fatal hepatotoxicity (rare)

  27. Alcohol addiction treatment • Naltrexone • Opioid antagonist • May reduce cravings for alcohol • SE: nausea+vomiting, headaches, fatigue • Contra-indications: Increased LFT’s, pregnant +breastfeeding, opioid dependence

  28. Opiate withdrawal • Nausea/vomiting, diarrhea, sweating, lacrimation • Piloerection • Pupillary dilatation • Myalgias • Dysphoric mood, insomnia, anxiety • Not life threatening, but uncomfortable

  29. Opiate cessation • Stopping «cold turckey» • Supportive measures,Clonidine as adjunct • Tapering schedule with long-acting opiate • Equivalence; decrease by 10%/week • Maintenance treatment • Methadone (full agonist) • Buprnorphine/Naloxone (Suboxone) (partial agonist)

  30. Methadone replacement Synthetic opioid Useful if high dose opiate abusers, addicted for a long time, relapses, etc. MD’s need a special license to order Usually daily pick-up at pharmacy

  31. Safe prescribing – controlled substances • Under Canada’s Controlled Drugs and Substances Act • Narcotics and other drugs of potential for abuse (methylphenidate, benzodiazepines and barbiturates) • Need to correctly identify patient • Information can be collected by Narcotics Safety and Awareness Act (NSAA) • Should never write repeats on narcotic prescription

  32. Nicotine… • Counselling, advice • Nicotine replacement therapy • Patch, gum, inhaler, lozenges • Usually treat for up to 2-3 months • Bupropion (Zyban) • Usually 2 months of treatment, up to 1 year • Contraindicated in Seizure disorder

  33. Nicotine… • Varenicline (Champix) • Some studies have showmn exacerbation of pre-existing psychiatric conditions – so monitor • Usually treat for 3 months

  34. Prevention/harm reduction strategies • Safer environment to use substances • Supervised injection sites • Safer use of substances • Crack pipe programs, needle exchange programs • Alternative safe substances • Methadone Maintenance • Modification/Management of related risk behaviours • HIV/STD screening • Safe sex education • Condoms

  35. References • Dr Willow’s presentation, substance use • DSM-IV • Toronto Notes • Up to date • Narcotics Safety and Awareness Act • Canada’s low risk alcohol drinking guidelines

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