Treatment of Alcoholism and Addiction Steven R. Ey, M.D. Medical Director Genesis Chemical...
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Transcript of Treatment of Alcoholism and Addiction Steven R. Ey, M.D. Medical Director Genesis Chemical...
Treatment of Alcoholism and Addiction
Steven R. Ey, M.D.
Medical Director
Genesis Chemical Dependency Unit
South Coast Medical Center
Laguna Beach, CA
April 14, 2005
Addiction Reward Pathway
Admission Labs
Labs (BAL, CBC, Chem 22, Mg, TSH, RPR, lipase, UDS, UA, pregnancy test)
PPD CXR EKG Acetaminophen and salicilate level as
indicated
Absorption and Metabolism
Sites include stomach, small intestine, and colon Dependent on gastric emptying time Metabolized primarily in the liver by oxidation Alcohol dehydrogenase exhibits zero-order kinetics
(15 mg/dl/hr) Proportional to body weight Microsomal ethanol oxidizing system (MEOS) Alcohol inhibits cytochrome P-450
Alcohol Breakdown
Alcohol ADH
AcetaldehydeALDH
Acetic acid and water
Alcohol Intoxication
20-99mg% loss of muscular coordination, change in behavior
100-199mg% ataxia, mental impairment 200-299mg% obvious intoxication, nausea
and vomiting 300-399mg% severe dysarthria and amnesia
Alcohol Intoxication cont.
400-600mg% coma occurs 600-800mg% decreased respirations and
blood pressure, obtundation, often fatal Important to remember the role of tolerance
in all these categories
Management of Alcohol Intoxication
Cardiovascular and respiratory support to control blood pressure and maintain airway
Intravenous fluids (“Banana Bag-NS, thiamine, MVI, Folate, B-12)
Assess for other drug use especially benzo’s or opioids as antagonists can be used
Closely monitor until withdrawal begins and then start treatment
Monitoring Alcohol Withdrawal
MSSA (Modified Selective Severity Assessment)
CIWA-A (Clinical Institute Withdrawal Assessment for Alcohol)
Advantage for personnel to monitor progress and treat accordingly
Disadvantage is cookbook approach
Withdrawal Signs and Symptoms
Tremor Agitation Autonomic changes (BP, HR, Temp.) Seizures Sensorium changes (eg, hallucinations,
confusion)
Withdrawal Syndrome Stage 1
Begins within 24 hours Lasts up to 5 days 90% of cases do not go beyond stage 1 Other symptoms include depressed mood,
anxiety, diaphoresis, headache, nausea/vomiting, etc.
Withdrawal Syndrome Stage 2
Mostly untreated or undertreated in stage 1 Same signs and symptoms in stage 1 only
more severe Hallmark is hallucinations (generally
perceived as benign) Usually occurs 48 hours after last drink
Withdrawal Syndrome Stage 3
Usually occurs 72 hours after last drink Delirium Tremens (acute reversible organic
psychosis) has 2% mortality Lacks insight into hallucination, often
disoriented and labile Seen in persons with severe alcoholism
and/or significant medical problems
Detoxification Treatment
Begin benzodiazepine at onset of withdrawal symptoms
Be cautious that symptoms are withdrawal and not intoxication
If uncertain repeat BAC to be sure it is decreasing before sedating detoxification meds are instituted
Detox Pharmacology
Benzodiazepine and Barbiturate equivalents: Diazepam 10mg Lorazepam 2mg Phenobarbital 30mg Chlordiazepoxide 25mg Oxazepam 30mg
Detox Pharmacotherapy
Know 2-3 drugs well for routine detox (e.g., Diazepam 10-20 mg Q1 hr prn withdrawal)
Magnesium sulfate 2 gm for severe withdrawal (esp. in seizure risk)
Daily thiamine 100 mg, folate 1mg, and MVI Push fluids Supportive therapy (eg hypertension meds, etc.) Stage 3 withdrawal usually requires iv fluids, foley
catheter, soft restraints, etc.
Alcohol Withdrawal Seizures
More common in untreated alcoholics Should hospitalize if first seizure Need to be evaluated for other causes (eg, head injury,
CVA, or CNS infection, etc.) if first seizure or history not clear
Work up includes brain imaging and EEG 1 in 4 patients have a second seizure within 6-12 hours Must report any seizure to County Health Dept. and
inform patient not to drive
Alcohol Withdrawal Seizures
Mostly Grand mal seizures Usually 24-48 hours after last drink but may
be within 8 hours BAC does not have to be zero Less than 3% become status epilepticus Increased risk if prior seizure or detoxing off
sedative hypnotic as well
Substance Abuse, J Lowinson, MD. Third Edition, 1997, page 129.
GABA and NMDA Neuronal Receptors
Kindling and Seizures
Alcohol Withdrawal Seizure Treatment
Parenteral benzodiazepines (eg, ativan 2 mg or valium 10 mg iv stat)
Seizure precautions Valium 10-20 mg q1 hour prn or scheduled taper Anti-convulsants are generally not indicated unless
the diagnosis is in doubt Work up if 1st seizure Report to County Health Dept. and no driving until
cleared
Pharmacotherapy Treatment
Disulfiram Naltrexone Acamprosate
Disulfiram
Deterrent therapy Inhibits metabolism of alcohol by blocking
acetaldehyde dehydrogenase Acetaldehyde is toxic product causing the reaction
(flushed, tachycardia, diaphoresis, nausea, headache, etc.)
Metronidazole and alcohol may cause disulfiram like reaction
Disulfiram (cont.)
Prescribing tips (read the label for alcohol if not sure)
Monitor liver enzymes May cause psychosis Evaluate need for patient to take in front of
staff
Volpicelli, 1992
Naltrexone
Opiate blocker Evidence for reduced cravings and relapse
rates 23% relapsed vs. 54% placebo during 12
week study Definition of relapse
Krystal, et al. NEJM Volume 345, pg. 1734-39, Dec 13, 2001
Naltrexone cont.
VA study Dec 13, 2001 NEJM 627 veterans given 12 mo Naltrexone, or 3
mo. Naltrexone and 9 mo placebo, or 12 mo placebo
No statistically significant difference in # days to relapse at 13 weeks, and no difference in % days drinking at 52 weeks
Acamprosate
Affinity for GABA A and GABA B receptors
Inhibits glutamate effect on NMDA receptors
Now available in the United States
Acamprosate cont.
Multiple studies in Europe show it effectiveness and safety
Tempesta, et al. (2000) found abstinence rate 57.9% with acamprosate versus 45.2% with placebo
Sass, et al. (1996) found at the end of 48 weeks of treatment and 48 more weeks of follow-up that 39% of the acamprosate group vs. 17% of the placebo group remained abstinent
Case Scenario #1
40 y.o. male admitted with BAC 460 mg/dl. Communicates clearly History of recent Alcohol Withdrawal
Seizure History of multiple AMA’s during detox in
the past
Case Scenario #1 Treatment
Patient has high tolerance so medicate appropriately Monitor closely and repeat BAC to ensure it is
decreasing May use Librium 100 mg po or Phenobarbital 130
mg im to decrease risk of seizure Start valium 10-20 mg q 1 hour prn (or Ativan) Begin thiamine 100 mg, folate 1 mg, & MVI daily 2 gm MgSO4 if withdrawal difficult or Mg low Consider Depakote or Dilantin but not necessary
Case Scenario #2
55 y.o. female drinking 1 bottle wine per day and taking xanax 4 mg. per day
Smokes 1 pack per day cigarettes Complains of hip pain, fell 1 week ago
Case Scenario #2 Treatment
Alcohol detox with usual meds or Phenobarbital Slow klonopin taper as outpatient is one option but
there are more (eg anti-seizure meds and quick taper in hospital) to detox off of Xanax
Smoking cessation program Don’t forget to check the hip pain.
Case Scenario #3
30 y.o. female drinking 1-2 bottles of wine per day
History of Bulimia nervosa, last binge/purge 3 months ago
History of multiple relapses
Case Scenario #3 Treatment
Pregnancy test positive! OB/GYN consult but you can order an
ultrasound now Always treat as if they will keep the baby Detox med of choice is Phenobarbital Extended care in dual diagnosis program
Opioid Dependence
Physiologic dependence versus addiction Common opioids Rx drugs on the streets, etc. Abuse patterns
Opioid Withdrawal Signs
COWS Scale Elevated HR & BP, diaphoresis, restlessness,
pupil size, bone or joint aches, runny nose or tearing, GI upset, tremor, yawning, anxiety or irritability, gooseflesh skin
Score items stage to withdrawal
Opioid Treatment
Clonidine 0.1 mg every 2 hours prn Benzodiazepine or barbiturate prn (eg,
Phenobarbital 15-30 mg every 3 hours prn) NSAID Muscle relaxant (eg, methacarbamol) Bentyl for abdominal cramps Sleeping agent (eg, temazepam)
Opioid Treatment (cont.)
Subutex (buprenorphine) Suboxone (buprenorphine/naloxone) Sublingual administration of partial opioid
agonist Must be certified through DEA to use
Treatment with Suboxone
Certification requires ASAM, Addiction Psychiatry, or 8 hour training course
Capacity to provide or to refer patients for necessary ancillary services
Treat no more than 30 patients at one time
Opioid Case #1
45 y.o. female taking increasing doses of hydrocodone per day
Currently on 90 mg per day Repeatedly calling office, loses prescriptions No pain etiology to explain use of narcotics
Opioid Case #1 Treatment
Recommend inpatient detox in CD program Consider outpatient detox only in reliable,
motivated patient Clonidine 0.1 mg q 2 hrs. prn, NSAID,
Muscle relaxant, bentyl, benzo’s for anxiety and insomnia
Most CD programs using suboxone now
Sedative/Hypnotic Dependence
Difficult to detox Seizure prophylaxis important Rebound anxiety needs to be treated Methods to obtain meds include legitimate
prescriptions, prescription fraud, multiple MD’s or clinics, internet, foreign countries and the street
Sedative/Hypnotic Treatment
Taper as outpatient 10% of dose per week as outpatient
Quick taper as inpatient with anti-seizure meds
Consider valproic acid or other anti-seizure med for equivalent doses of valium 30 mg. per day or more (based on clinical experience)
Sedative/Hypnotic Case #1
32 yo male taking xanax for 3 years Began with xanax 0.5 mg. BID Now taking 6 mg. per day for 3 months Also on SSRI No history of seizure
Sed/Hyp Case #1 Treatment
Equivalent dose of valium 60 mg. per day Likely to have seizure if stops abruptly Recommend inpatient detox Start valproic acid 250 mg. QID, keep on therapeutic
dose minimum 6 weeks Substitute benzo or barb with limited doses for 5-7
days Consider zyprexa or equivalent Continue SSRI
Psychostimulants
Detox not a covered benefit Medical complications usually bring patient
to ER May admit for workup of Chest pain, CVA,
seizure, etc. Referral to program
Nicotine
Fagerstrom Test Nicotine Replacement (gum, patches) Bupropion Support Groups