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 п‚— DonвЂ™t miss head trauma п‚— DonвЂ™t miss GI problems п‚— DonвЂ™t miss metabolic disturbances п‚— DonвЂ™t miss infections п‚— DonвЂ™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 п‚— FIRST DOSE вЂ“ п‚— 50 вЂ“ 100 mg Chlordiazepoxide п‚— 20 вЂ“ 40 mg Diazepam п‚— REASSESS IN ONE HOUR п‚— If still symptomatic repeat the dose and reassess п‚— If calm, asymptomatic вЂ“ plan taper п‚— CONSIDER TAPER OVER 3 вЂ“ 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 п‚— BZ вЂ“ 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 п‚— 30 yo вЂњparty girlвЂќ 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 п‚— 41 yo logger who presents to your office wanting to вЂњquit drinkingвЂќ 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 п‚— DONвЂ™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 п‚— вЂњAlcohol withdrawalвЂќ www.essentialevidenceplus.com п‚— вЂњManagement of moderate and severe alcohol withdrawal syndromesвЂќ www.uptodate.com п‚— вЂњAmbulatory alcohol detoxificationвЂќwww.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.