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Managing Alcohol Withdrawal

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Managing Alcohol
Withdrawal
SECSAT
SBIRT CURRICULUM
2010
Hunter Woodall, MD
AnMed Health, Anderson, SC
Funded by:
www.sbirtonline.org
Objectives
Identify signs and symptoms of alcohol withdrawal
Discuss methods of treating alcohol withdrawal in the
inpatient setting
Identify the resources needed for outpatient alcohol
detox
Clinical Syndrome
п‚— Alcohol is a CNS depressant
п‚— Alcohol hits >30 CNS receptors
п‚— Withdrawal seems to involve GABA,
norepinephrine, & serotonin
п‚— Signs and symptoms
п‚— begin 4-12 hours
п‚— peak at 24-48 hours
п‚— resolve in 4-5 days (SORT C)
STEPS IN MANAGING
WITHDRAWAL
п‚— History and Physical
п‚— Estimate risk of severe withdrawal and
seizures
п‚— Assess level of withdrawal
п‚— Implement a protocol
п‚— Remember the cocktail
п‚— Follow-up assessment
п‚— BI or RT or RX when pt comprehending
HISTORY AND PHYSICAL
п‚— Withdrawal is often not the only problem
 Don’t miss head trauma
 Don’t miss GI problems
 Don’t miss metabolic disturbances
 Don’t miss infections
 Don’t miss other intoxications
HOW BAD WILL IT BECOME?
Risk factors for severe withdrawal:
п‚— Age >30
п‚— Chronic heavy drinking (>12 a day)
п‚— Hx of generalized seizures
п‚— Hx of previous withdrawal
п‚— Other intoxications
п‚— Presence of comorbid conditions
ASSESS WITHDRAWAL
п‚— General Symptoms
п‚— Autonomic Signs
п‚— Seizures
п‚— Hallucinations
п‚— Delirium and Psychosis
Alcohol and Sedative Hypnotic
Withdrawal Stages
General Signs
Hallucinations
Delirium
Stage 1
mild
no
no
Stage 2
moderate
yes
no
Stage 3(DTs) severe
probable
yes
IMPLEMENT A PROTOCOL
п‚— BENZODIAZEPINE PROTOCOLS
п‚— CIWA-AR
п‚— FIXED DOSE/TAPER
п‚— LOADING DOSE/TAPER
п‚— ANTICONVULSANT PROTOCOLS
Benzodiazepines are the
Treatment of Choice
EVIDENCE
п‚— Best to ward off seizures (SORT A)
п‚— Better than placebo for symptoms
(SORT A)
п‚— Better prevention of Delirium
A)
(SORT
п‚— Wide therapeutic window (SORT C)
BENZODIAZPINES EQUIVALENTS
п‚— Chlordiazepoxide (Librium) 25mg
п‚— Diazepam (Valium) 10mg
п‚— Oxazepam (Serax) 15mg
п‚— Lorazepam (Ativan) 1mg
CIWA-Ar
Clinical Institute Withdrawal Assessment from Alcoholrevised
CIWA-Ar
SCORES DRIVE DOSING
п‚— <8 no medicine
п‚— >8
п‚— Chlordiazepoxide (Librium), 50 to 100 mg
п‚— Diazepam (Valium), 10 to 20 mg
п‚— Lorazepam (Ativan), 2 to 4 mg
CIWA-AR
п‚— REASSESS IN ONE HOUR
п‚— DOSE BY SCORE AGAIN
п‚— REPEAT UNTIL SCORE STAYS <8
п‚— CONTINUE TO MONITOR (Q2-4)
FIXED DOSE BZ PROTOCOL
п‚— Recommended by ASAM years ago but replaced
by symptom-triggered protocols
п‚— Categorizes the pt as either low or high risk by
daily drinking amounts, then uses standard tapers
BZ LOADING
п‚— Can be useful if one needs the pt quiet
п‚—
п‚—
п‚—
п‚—
quickly and one can protect the airway
Useful for mild withdrawal
Still requires reassessment
Tapering maybe unnecessary
Can be used in outpatient setting
ORAL BZ LOADING PROTOCOL
 FIRST DOSE –
 50 – 100 mg Chlordiazepoxide
 20 – 40 mg Diazepam
п‚— REASSESS IN ONE HOUR
п‚— If still symptomatic repeat the dose and reassess
 If calm, asymptomatic – plan taper
 CONSIDER TAPER OVER 3 – 5 DAYS
п‚— REASSESS DAILY
WHY USE SYMPTOM-TRIGGERED
PROTOCOLS?
п‚— The CIWA-AR better than fixed dosing (SORT B)
п‚— Just as safe
п‚— Less sedation
п‚— Less medications
п‚— Less time in treatment
п‚— Less expense
ANTICONVULSANTS I
п‚— 2005 Cochrane review (SORT A)
п‚— Not significantly better than placebo for symptom
control
п‚— Not significantly better than other drugs for seizure
control
п‚— Needs much more data
ANTICONVULSANTS II
Tiagabine (Gabitril) investigated 2005
п‚— Pilot study (13 patients)
п‚— Similar results to oxazepam and lorazepam
п‚— Trend towards less post-detox drinking
п‚— Carbamazepine used widely in Europe
п‚— Recommended in addition to BZ for pts at high
risk for seizures
Avoiding Seizures I
п‚— Who should receive prophylactic treatment?
п‚— Patients already on anticonvulsants
п‚— History of epilepsy
п‚— History of withdrawal seizures
п‚— Magnesium <1.2 mg %
Avoiding Seizures II
п‚— Prophylactic Medication:
п‚— Carbamazepine is preferred over phenytoin
п‚— Give as early as possible
п‚— Dosage: 100 mg every 2 hours x 4 doses
п‚— Then 200 mg every 6 hours x 7 days (SORT ?)
THE COCKTAIL
п‚— THIAMINE
п‚— MVI WITH FOLATE
п‚— MAG SULFATE ONLY IF LOW
п‚— IV FLUIDS?
REASSESSMENT I
п‚— MUST BE DONE IN ONE HOUR
п‚— NURSING TASK IF ON SYMPTOM-TRIGGERED
PROTOCOL
п‚— STAY IN CONTACT WITH YOUR NURSING TEAM
REASSESSMENT II
п‚— Complicated patients with secrets
п‚— Reconsider infections, trauma, other intoxications,
metabolic problems, & comorbid diseases
п‚— Is the withdrawal better or worse?
п‚— Add magnesium or antipsychotic or
carbamazepine?
п‚— Consultations?
Other Medications Used in
Alcohol Withdrawal
п‚— Beta-blockers can control hypertension
п‚— Clonidine can reduce symptoms and BP
п‚— Haloperidol (Haldol) or Ziprasidone
(Geodon) for persistent psychosis
given IM)
п‚— Hydoxyzine for itching
(can be
WHEN THE PT IS BETTER
п‚— Brief Intervention?
п‚— Refer for Treatment?
п‚— Consider Adjunct Meds
п‚— Naltrexone
п‚— SSRI
п‚— For depression
п‚— For anxiety
п‚— Pain Control
OUTPT DETOX I
п‚— Make the diagnosis
п‚— Assess Medical risks
п‚— Suicide Risk
п‚— True seizure disorder
п‚— Serious acute illness
п‚— Hx of serious withdrawal
OUTPT DETOX II
Agrees to treatment
п‚— Intensive Outpatient
п‚— At least AA
п‚— Assess social support/safety
п‚— Will they come back?
п‚— Will a family member handle meds?
п‚— Will a friend watch over them?
Symptomatic Outpatients
Can assess with CIWA-Ar
п‚— Sit up & drink water prior to each
dose (low aspiration risk)
п‚— Observe for 1 hr after each dose
п‚— Can go when score is <
п‚— If tapering, write for just enough
meds to get to the next visit
п‚— Reassess every day
Management of Asymptomatic
Patients
п‚— Schedule for re-evaluation in 24 hours
п‚— If still asymptomatic
п‚— Encourage abstinence and AA
п‚— Consider drug therapy
п‚— Follow up in 1 week
PETER PAINTER
п‚— 40 yo painter found down with right ear laceration
п‚— PE reveals: intermittent nausea, beads of sweat,
restlessness, moderate anxiety, tremor with hands
extended, moderate headache, mild parethesias, oriented to
place, off on date(1day), denies hallucinations, 160/90, 120,
99.6
п‚— Labs unremarkable, CT -, etoh level= 20 mg/dl
п‚— No hx of withdrawal or seizures in the past
п‚— Score his CIWA-Ar
п‚— Write his alcohol withdrawal orders
PETER II
п‚— CIWA-Ar Score = 28
 BZ – loading dose
100 mg chlordiazepoxide
п‚— 40 mg diazepam
п‚— 4 mg lorazepam
п‚— Then CIWA protocol
п‚— ICU, IV, H2 blocker, thiamine, MVI
п‚—
PETER III
п‚— After one hour Peter still has a score over 20 and
is requiring restraints to stay in bed and keep his
IV intact.
п‚— What would you do now?
PETER IV
п‚— Strongly consider lorazepam drip
п‚— Consider adding antipsychotic
п‚— Consider adding carbamazepine
п‚— Continue to assess
Polly Pumpkineater
 30 yo “party girl” who presents to the ED on
Nov 1 with visable tremors.
п‚— Vomited only once, mild headache
п‚— Palms moist, feels restless but sits still
п‚— Oriented but cannot add well
п‚— Mild anxiety, no hallucinations, mild
parathesias
п‚— Tremor with hands extended
п‚— What is her CIWA-Ar?
Polly II
п‚— CIWA-Ar = 16
п‚— BTW- no seizure history, on SSRIs, moderately
suicidal without plans
п‚— This could be handled in observation or inpatient.
The CIWA-Ar protocal often works quite well is
this setting.
WOODY WOODSMAN
 41 yo logger who presents to your office wanting to “quit
drinking”
п‚— He still works every day (except Mondays after holidays)
п‚— You consider outpatient detox -what do you want to know?
WOODY II
п‚— He lives with common law wife who does not
drink.
п‚— He never had seizures.
п‚— He will attend IOP and AA.
п‚— He is otherwise healthy.
п‚— CIWA-Ar is 10
п‚— Outpatient regimen?
WOODY III
п‚— Load with C100 mg
п‚— Reassess in one hour
п‚— Additional history:
п‚—
п‚—
п‚—
Somewhat depressed, not suicidal
Gulf War Vet with possible PTSD
Father recently died of cirrhosis
WOODY IV
п‚— CIWA-Ar <8 in one hour
п‚— Medications will be controlled by his wife
п‚— Write his taper.
п‚— How do you follow up?
WOODY V
п‚— Write enough Chlordiazepoxide 50mg bid
tapering to 25 bid
п‚— +Set up referral to outpt rehab
п‚— Tell wife about Al-Anon
п‚— Follow up in person or by phone each day
SUMMARY
п‚— ASSESS AND REASSESS
п‚— USE BZ EARLY AND OFTEN
п‚— SYMPTOM-TRIGGERED PROTOCOLS ARE THE
BEST STRATEGY
 DON’T JUST DETOX, RX THE UNDERLYING
CONDITION
п‚— CAN DO OUTPTS WITH CARE
REVIEWS
п‚— Management of drug and alcohol withdrawal.
Kosten TR, OConnor PG. NEJM 2003. 348:178695..
п‚— Ambulatory Detoxification of Patients with
Alcohol Dependence. Blondell RD.
AFP.
2005;71:496-502
п‚— Alcohol withdrawal syndrome. Bayard et al. AFP.
2004;69:1443-1450
E RESOURCES
п‚— Table of the systemic reviews of interventions for alcohol
dependence. Database of Abstracts of Reviews of Effects.
Baker P, Young M, Thomas R. 2006.
http://www.health.qld.gov.au/ph/documents/caphs/321
04.pdf
 “Alcohol withdrawal” www.essentialevidenceplus.com
 “Management of moderate and severe alcohol withdrawal
syndromes” www.uptodate.com
 “Ambulatory alcohol detoxification”www.uptodate.com
Foundational Articles
п‚— Assessment of alcohol withdrawal: the revised clinical institute
withdrawal assessment for alcohol scale (CIWA-Ar). Sullivan et al.
Br J Addict. 1989;84:1353-7
п‚— Saitz R, Mayo-Smith MF, Roberts MS, Redmond HA, Bernard DR,
Calkins DR. Individualized treatment for alcohol withdrawal.
JAMA. 1994; 272(7): 519-523.
п‚— Holbrook et al. Meta-analysis of benzodiazepine use in the
treatment of alcohol withdrawal. CMAJ.1999;160:649-655.
п‚— Symptom-triggered versus fixed-schedule doses of benzodiazepines
for alcohol withdrawal. Daeppen et al. Arch Intern Med. 2002.
162:1117-21.
Cochrane Reviews
п‚— Benzodiazepines for alcohol withdrawal.
Ntais et al. Cochrane Review. 2006
п‚— Anticonvulsants for Alcohol withdrawal.
Polycarpou et al. Cochrane Review. 2006
Guidelines
п‚— Detoxification and substance abuse treatment:
physical detoxification services for withdrawal
from specific substances. SAMHSA 2006.
www.guidelines.gov
п‚— Mayo-Smith et al. Management of alcohol
withdrawal delirium: an evidence based
practice guideline. ( ASAM working group)
п‚— Arch Int Med 2004; 1264:1405-12.
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