Outpatient Treatment of Alcohol and Opioid Withdrawal

1. Outpatient Treatment of Alcohol and Opioid Withdrawal Emjay Tan, M.D. KP SSF Psychiatry Dept CME Presentation 12 October 2018

2. What We Will Cover Today • Screening, diagnosis, and assessment • Alcohol withdrawal treatment • Opioid withdrawal treatment • When to refer to ER • HealthConnect detox smartphrase: .DETOXEVAL

3. DSM-5 Alcohol Use Disorder Criteria • Problematic pattern of alcohol use with at least two symptoms within 12-month period • 1. Alcohol taken in larger amounts or over longer period of time than intended • 2. Persistent desire or unsuccessful efforts to cut down or control alcohol use • 3. A lot of time spend in obtaining alcohol, using alcohol, or recovering from it • 4. Cravings • 5. Failure to fulfill major role obligations at work, school, home • 6. Continued use despite social/interpersonal problems • 7. Giving up important social, occupational, or recreational activities because of alcohol

4. DSM-5 Alcohol Use Disorder Criteria (cont.) • 8. Recurrent alcohol use in physically dangerous situations • 9. Continued alcohol use despite physical/psychological problems • 10. Tolerance • 11. Withdrawal • Severity specifiers: • 2-3 symptoms  Mild • 4-5 symptoms  Moderate • ≥6 symptoms  Severe

5. “Five C’s of Addiction” • 1. Cravings • 2. Compulsion (use to relieve negative feeling states) • 3. Loss of Control • 4. Continued use despite negative Consequences • 5. Chronic

6. Screening and Assessment Tools for Substance Use Disorders

7. CAGE • 1. Have you ever felt you need to Cut down on your drinking? • 2. Have people Annoyed you by criticizing your drinking? • 3. Have you ever felt Guilty about drinking? • 4. Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover? - 1 point  possible alcohol use disorder - ≥2 points  probable alcohol use disorder

8. NIAAA-1: Single Screening Question for Alcohol • “How many times in the past year have you had x or more drinks in a day?” • Females: x = 4 • Males: x = 5 Any response other than “never” should trigger more assessment for alcohol use disorder, i.e., AUDIT questionnaire

9. AUDIT: Alcohol Use Disorders Identification Test • See handout • Score ≥8 is considered threshold for likelihood of alcohol use disorder

10. CAGE-AID (“Adapted to Include Drugs”) • In the last 3 months… • 1. have you felt you should Cut down or stop drinking or using drugs? • 2. has anyone Annoyed you or gotten on your nerves by telling you to cut down or stop drinking or using drugs? • 3. have you felt Guilty or bad about how much you drink or use drugs? • 4. have you been waking up wanting to have an alcoholic drink or use drugs? (Eye-opener) • 1 point  possible substance use disorder • ≥2 points  probable substance use disorder

11. NIDA-1: Single Screening Question for Drugs • “How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons?” Any response other than “never” should trigger further assessment for substance use disorder; i.e., give DAST-10 questionnaire

12. DAST-10: Drug Abuse Screening Test • See handout

13. CRAFFT: Adolescents and Young Adults • C: Have you ever ridden in a CAR driven by someone (including yourself) who was “high” or had been using alcohol or drugs? • R: Do you ever use alcohol or drugs to RELAX, feel better about yourself, or fit in? • A: Do you ever use alcohol or drugs while you are ALONE? • F: Do you ever FORGET things you did while using alcohol or drugs? • F: Do your family or FRIENDS ever tell you that you should cut down on your drinking or drug use? • T: Have you ever gotten into TROUBLE while you were using alcohol or drugs? • ≥2 positive responses constitutes a positive screen

14. DSM-5: Alcohol Withdrawal • Two or more of following sx, within several hrs to a few days after cessation of (or reduction in) alcohol use: • Autonomic hyperactivity • Increased hand tremor • Insomnia • Nausea or vomiting • Transient visual, tactile, or auditory hallucinations or illusions • Psychomotor agitation • Anxiety • Seizures

15. Alcohol Withdrawal Severity • ~95% of patients with alcohol withdrawal experience mild-moderate severity of symptoms • Usually resolve within several days • Most don’t even require medication (but we often treat anyway) • ~5% experience severe withdrawal • Seizures • Peak incidence ~24 hrs after last drink, usually a single seizure or a burst of several seizures over a few hours; <3% evolve in to status epilepticus • Delirium tremens • ~72-96 hrs after last drink; agitated delirium, severe autonomic hyperactivity, severe tremor, confusion, hallucinations (usually visual or tactile)

16. https://evidencebasedpractice.osumc.edu/Documents/Guidelines/AlcoholWithdrawal.pdfhttps://evidencebasedpractice.osumc.edu/Documents/Guidelines/AlcoholWithdrawal.pdf

17. Blood Alcohol Concentration • If a pt’s clinical presentation does not match what is typically expected from BAC, may need to be more concerned for severe withdrawal (e.g., BAC = 300 mg/dL, but pt is not ataxic, speech clear, alert, seems comfortable, etc.) • Sometimes, pts who have very high tolerance levels can start to experience acute alcohol withdrawal even if BAC is still quite elevated (but is on its way down) (e.g., BAC = 100 mg/dL, but pt already anxious, tremulous, sweaty, elevated VS, dilated pupils, etc.) • Body typically metabolizes alcohol at rate of ~15 mg/dL per hour

18. Prediction of Alcohol Withdrawal Severity Scale • A tool used to assist in the identification of patients at risk for complicated/severe alcohol withdrawal which was developed after a literature search which identified 10 items which may be correlated with risk for complicated AWS. 1 • It has been validated in 2 studies: a pilot and a follow up study. • Using the cut off of 4, the tool's sensitivity for identifying complicated AWS is 93.1%, specificity is 99.5% positive predictive value is 93.1% and negative predictive value is 99.5%2 Maldonado JR, Sher Y, Ashouri JF, et al. The “Prediction of Alcohol Withdrawal Severity Scale” (PAWSS): Systematic literature review and pilot study of a new scale for the prediction of complicated alcohol withdrawal syndrome. Alcohol. 2014; 48: 375-390 Maldonado JR, Sher Y, Das S, et al. Prospective Validation Study of the Prediction of Alcohol Withdrawal Severity Scare (PAWSS) in Medically Ill Inpatients: A New Scare for the Prediction of Complicated Alcohol Withdrawal Syndrome. Alcohol and Alcoholism. 2015; 50(5) 509-518

20. Treatment of Alcohol Withdrawal • Many methods • Benzodiazepine fixed taper • Symptom-triggered use of benzodiazepines (i.e., CIWA-Ar protocol) • Benzodiazepine-sparing protocols • In outpatient setting, most common approach is to used fixed taper, with guidance to the patient/caregiver on when to hold medication • In outpatient setting, can also use benzodiazepine-sparing protocol (may eventually become the method-of-choice) • Symptom-triggered use of benzodiazepines (CIWA-Ar protocol) requires more frequent monitoring, usually with RN support, either in partial hospital or inpatient setting

21. Alcohol Detox – Fixed Schedule Taper Examples • Lorazepam preferred for elderly pts, or pts with liver disease • Supplement with thiamine 100 mg/d x 30 days to prevent Wernicke-Korsakoff’s syndrome • For patients with more severe withdrawal, can start with more frequent dosing, and can lengthen the taper • For patients with less severe withdrawal, can start with lower doses, less frequent dosing, and briefer taper

22. Alcohol Detox – Fixed Schedule Taper (cont.) • Usually results in pts receiving more benzodiazepines than they need • Involves a bit of guesswork about dosing of benzodiazepines • Tell the pt: “You can take up to this amount, but not more. You will likely need less. If you feel comfortable, or a bit sleepy, you can skip a dose, or wait a couple extra hours. Don’t feel like you have to finish the prescription. If you don’t need all of it (and you likely won’t), throw the rest away. I will give you a phone call in the next 3-4 days to see how you’re doing, and I’d like you to have a follow-up clinic appointment with a psychiatrist or your PCP within 1 week.”

23. Alcohol Detox – Symptom Triggered Treatment Using CIWA-Ar • More appropriate for partial hospital or inpatient setting • CIWA-Ar score obtained by RN’s used to guide benzodiazepine dosing • Usually, less benzodiazepines administered to the pt, while still covering symptoms • Takes some guesswork out of prescribing benzodiazepine dose • However, pts with comorbid medical issues can have false elevations in CIWA-Ar score, resulting in too much, or inappropriate, benzodiazepine dosing CIWA-Ar – “Clinical Institute Withdrawal Assessment – Alcohol, revised”

24. CIWA-Ar (cont.) • See handout • Sample protocol: • RN rates CIWA score every 4 hours • If CIWA < 8, no medication • If CIWA 8-13, administer lorazepam 1 mg, and check CIWA again in 1 hour • If CIWA 14-20, administer lorazepam 2 mg, and check CIWA again in 1 hour • If CIWA ≥ 21, administer lorazepam 4 mg and notify physician, and check CIWA again in 1 hour • Option: If you want to, you can document a single CIWA-Ar score in outpatient clinic assessment to guide/support prescription for fixed benzodiazepine taper

25. Alcohol Detox: Rationale for Benzo-Sparing Protocol • Try to reduce incidence of delirium in patients with alcohol use disorder going through withdrawal • ~80-95% of patients going through alcohol withdrawal do not need medications to treat withdrawal symptoms • Due to down-regulation of GABA-A receptors in the brains of patients with chronic heavy alcohol use, and also the changes in subunit composition of those GABA-A receptors, benzodiazepines often don’t work as well in these patients going through alcohol withdrawal

26. GABA-A Receptor: Subunit Composition Changes in Chronic Alcohol Consumption

27. Alternatives to Benzodiazepines for Treatment of Alcohol Withdrawal  Less Likely to Cause Delirium • Alpha-2-agonists  lower BP, HR, anxiety, irritability, agitation • Clonidine - available PO, IV, and via patch • Guanfacine – PO only • Dexmedetomidine - IV; administered in ICU only • Antiseizure medications  prevent seizures, and also can help with anxiety, cravings, sleep • Gabapentin - PO only; contra-indicated if Cr > 1.5 mg/dL • Divalproex - PO or IV; contra-indicated if LFT’s too high or thrombocytopenia

28. Alpha-2-Agonists https://s-media-cache-ak0.pinimg.com/236x/d9/5f/d9/d95fd98f0e092e5f0e0f5b125f2f2d14.jpg

29. Antiepileptics Meir Bialer & H. Steve White. Key factors in the discovery and development of new antiepileptic drugs. Nature Reviews Drug Discovery. 2010; 9: 68-82

30. Benzodiazepine-Sparing Protocol: Example Can prescribe antiepileptic alone, or with alpha-2-agonist. (Generally wouldn’t use alpha-2-agonist alone, without antiepileptic, for alcohol withdrawal.)

31. Some Factors to Consider Referring to ER for Acute Alcohol Withdrawal • History of alcohol withdrawal seizures • History of delirium tremens • Other acute medical issues • Significantly elevated VS; e.g., SBP>200, DBP>100, HR>120 • Pt is confused, unable to follow directions

32. DSM-5: Opioid Withdrawal • Three or more of the following after cessation of (or reduction) in heavy/prolonged opioid use, or administration of an opioid antagonist: • Dysphoria • Nausea or vomiting • Muscle aches • Lacrimation or rhinorrhea • Pupillary dilation, piloerection, or sweating • Diarrhea • Yawning • Fever • Insomnia

33. https://www.workithealth.com/blog/opiate-withdrawal-timeline

34. COWS: Clinical Opioid Withdrawal Scale • See handout

35. Outpatient Treatment of Opioid Withdrawal • Many different approaches, but two most common are • Symptomatic treatment with clonidine and ancillary meds • Buprenorphine taper

36. Opioid Detox: Clonidine Protocol • Clonidine 0.1-0.2 mg PO q4-6 hrs x 2-4 days, then decrease to 0.1 mg PO q6-8 hrs x 2 days, then decrease to 0.1 mg PO q8-12 hrs x 2 days, then decrease to 0.1 mg PO qhs x 2 days, then stop • Pt may need highest totally daily doses of clonidine on days 2-4, rather than on the first day (depending on half-life of opioid) • Can also use guanfacine instead of clonidine • Can also use clonidine patch, in which case you would use oral clonidine on the first day only (to give time for clonidine from patch to reach steady state) • Warn patients about risk of orthostatic hypotension, dry mouth, sedation, and to stay well-hydrated • Clonidine seems to help primarily with autonomic s/sx of opioid withdrawal

37. Opioid Detox: Clonidine Protocol (cont.) • Ancillary meds used in conjunction with clonidine • Ibuprofen 600-800 mg PO q6-8 hrs prn muscle cramps or pain • Dicyclomine 10 mg PO q6 hrs prn abdominal cramps • Loperamide 2-4 mg PO prn loose stools (NTE 16 mg/d) • Ondansetron 8 mg PO q8 hrs prn N/V

38. Opioid Detox: Buprenorphine Taper • Suboxone • 4 mg SL bid x 2 days, then 2 mg SL bid x 2 days, then 2 mg SL qhs x 2 days, then stop • Some patient may need up to 12 mg/d for the first couple of days, followed by a slightly longer taper • The longer the patient is on Suboxone, the harder it is to stop • No need to use any ancillary meds with Suboxone • Make sure the patient is in at least moderate opioid withdrawal before taking first dose of Suboxone (usually at least 12-24 hours after last dose of short-acting opioid) • If not, there is risk of precipitated opioid withdrawal

39. Opioid Detox: When to Refer to ER? • Almost never • Minimal risk of medical complications from opioid withdrawal • In severe cases of dehydration due to intractable N/V or diarrhea, may need to send to ER for IV fluids

40. HealthConnectSmartphrase • .DETOXEVAL • May be useful if you are asked to do a “pop-in” to a therapist’s office • If you are doing a full intake (AAM4 or ADM4) then you will need to use this Smartphrase within your usual intake template in order to meet minimum charting standards

41. Tips for Doing Brief Detox Eval • Use .DETOXEVAL template to get essential elements of history • Assess degree of tremor, VS, if any clouding of sensorium is present, agitation, psychotic symptoms • Most of the time, withdrawal is mild • Not always necessary to do breathalyzer, unless you are worried about current intoxication and safety to drive • Provide maximum of 20-30 pills if prescribing benzodiazepine, less if pt’s withdrawal is very mild, or consider using gabapentin only • Follow-up TAV in ~2-4 days, follow-up office appt (with psychiatrist or PCP) within 1 week

42. Facilities for Inpatient Detox • HBS • Merritt Peralta Institute (MPI) • Contracted inpatient psychiatric hospital with dedicated detox unit • 3012 Summit St., Oakland, 5th floor • Part of Sutter Health’s Alta Bates Summit Medical Center • To request 5-7 day inpatient detox, call 510-869-8849 or 510-869-8850 and ask if bed is available • If bed is available, will need to place order in HealthConnect requesting approval from Outside Referrals Department

44. Facilities for Social Model Detox • County facilities, where patient brings detox meds, and the facility provides a place to sleep for several days, and locker to store the medication; useful for some pts with triggering living situations • Usually staffed by a counselor (no medical personnel) who may help to monitor patient’s compliance with medication • AA or NA meetings on-site • Examples • Palm Avenue Detox (San Mateo) • Cherry Hill Detox (San Leandro) • Helen Vine Recovery Center (San Rafael)