289. Alcohol and Other Drugs of Abuse

Alcohol Withdrawal

Alcohol Withdrawal Criteria: autonomic hyperactivity (sweating, HR>100), hand tremor, insomnia, n/v, hallucinations, agitation, anxiety, grand mal seizures.

Alcohol Withdrawal Seizures: occur as early as 6 hours after last drink, 90% occur in first 48 hrs. 40% only have 1 while 60% can have multiple. 85% will have their second seizure within 6 hours after the first one. Most can be discharged if treated appropriately, are uncomplicated, and have been observed for 3 hour period. 1/3 will go on to develop DTs. If seizures are partial, always get CT scan.

Alcohol Withdrawal Hallucinations: auditory/visual hallucinations without clouding of sensorium. Auditory more common. Usually at 12 hours.

Alcohol Withdrawal Delirium: acute or fluctuating level of consciousness, basically delirium. Also have electrolyte problems. 48 hours to 5 days out.

If > 5-7 days, likely fine, no need for treatment.

Management

Front loading vs symptom trigger approach

Front: rapid admin of long acting until there is a significant improvement in symptoms. Can lead to over sedation, but permits self-tapering. Titrated to development of lid-lag (sleepy, but a rousable). Don’t titrate to HR. Thats the end goal.

Symptom trigger approach: 4mg lorazepam q1hr given each time CIWA-Ar > 8. More common, though front loading has more rapid resolution of symptoms, less need for additional medications, and less reliance on withdrawal scales.

Don’t do standing oral benzos; stick more with symptom trigger. Causes increased amount of BZD, increased duration of treatment.

Not one benzo is superior to another. All GABA agonists.

Some people don’t respond well to benzos. Consider phenobarb, though increases rate of sedation. Severe withdrawal barbs can be more efficacious, though BZDs can work well.

Valium IV: quick onset, peak action in 15 minutes, long duration. Not good IM.

Ativan: short acting, excreted thru kidneys, can be given IV or IM. Single dose 2mg can reduce seizure reoccurrence down to 3%.

Propofol: short functional half-life may result in withdrawal symptoms when infusion discontinued. If intubated, stick with barbs first.

Baclofen: GABA agonist; better than placebo, Cochrane review concluded insufficient data yet.

Anticonvulsants promising, but not ready for prime-time. Carbamazepines / Valproate Рstudies show promise, somewhat hepatotoxic side effect. Oxcarbazepines Рno better than placebo for withdrawal in limited studies. Gabapentin Рdata is scattered, likely related to dose. 1200-1600mg seems to be the better dose.

Dexmedetomidine (Precedex): centrally acting alpha agonist. Like IV clonidine. Results in sedation/decrease HR/BP, no anticonvulsant therapy. Should not be used as monotherapy bc of this. Still controversial.

Phenobarb: can use with mild withdrawal – lasts so long, don’t need to re-dose. Binds GABA receptors. Half-life 2-7 days. The problem with benzos is that they don’t last long enough. Usually need to give prescription before they’re discharged. For inpatients. give 10mg/kg over 30 minutes. Reduces ICU admissions. Outpatient: 260mg IV, then can get second or third dose of 130mg. No need for prescription after discharge.

JEM, 2013. Highland Study: 10mg/kg pheno or placebo + ativan. No adverse events. Less ICU admissions.

AJEM, 2011. Fresno. 260mg IV. Then 130mg doses after that. Average was 500mg dose. Compared to ativan vs librium. No worsening side effects.

Seizures: Start giving ativan as soon as they hit the door to prevent recurrent seizures. Ativan ideal medication.

Clinical Institute Withdrawal Assessment for Alcohol-revised (CIWA-Ar): structured score used for treating alcohol withdrawal. 10 domains of symptoms with scores of 0-7.  Scores > 8 need medication. If the total score is below 10 after first dose of medicine, no further treatment recommended. Score Sheet Link.

Uncomplicated Withdrawal: Oral valium 10-20mg, Librium (chlordiazepoxide) 50-100mg oral, or IV Ativan 2-4mg every 1-2 hours until CWIA-Ar < 8.

Agitation: Don’t go with haldol if you can (tx it like treating with vec); doesn’t tx the underlying problem. Need to stick with GABA agonist.

Delirium: Titrate benzos until patient sleepy, but a rousable. Can give propofol (no greater than 48hrs or > 5mg/kg/h) for refractory DT.

Weingart’s DT protocol (Link): Give Valium IV push q5-10minutes, doses increase every 2-3: 10, 10, 20, 20, 20, 40, 40, 40. If still agitated/hyperdyanmic, either give phenobarb IV push (65mg, 130mg 260mg), or move toward intubation and start proposal and fentanyl drips. Also give thiamine and magnesium with dextrose containing fluids. Goal: Pt sleepy but a rousable with HR < 110. Bellevue’s protocol.

Disposition

Mild to moderate uncomplicated alcohol withdrawal responding well to initial ED tx can be discharged to detox unit or to supportive family with outpatient program referral. Ativan 2-4mg q4hrs x 5 days. Give CIWA sheet to family member and tell them to check every 6 hours – if >8, given dose. If not improving, have them bring them back in.

benzo

Admission: CIWA score > 15, advanced age, mild/moderate that does not respond to initial ED tx, comorbidities, prior hx/o DTs, seizures that require prolong observation, suicide, electrolyte abnormalities.

Resources

Tintinalli, Seventh Edition, Chapter 289: Alcohol and Other Drugs of Abuse

Crashing Patient: Alcohol Disorders and Withdrawal Disorders

USC EM Grand Rounds: Alcohol Withdrawal Treatment, Levine, Nov 21, 2013

Essentials of EM, 2013, Phenobarb for Alcohol Withdrawal, Greg Hendey

New Approach to Ethanol Abusers, Walt Lubbers, eMedHome, AAEM Scientific Assembly 2016

289. Alcohol and Other Drugs of Abuse

285. Psychotropic Medications and Rapid Tranquilization

Move toward the shouting and the odd behavior.

Agitation: excessive verbal behavior, excessive motor behavior, heightened arousal, purposeless movements, pacing, hand wringing, hair pulling, discomfort in one’s own skin.

4 objectives: ensure safety of patient, staff, and others; help the patient manage emotions and distress; avoid use of restraints; avoid coercive interventions. AVOID restraints if you can.

De-escalation: respect personal space, do not be provacative, establish verbal contact, keep it concise and simple, identify wants/feelings, listen to what the patient is saying, agree or agree to disagree, set clear limits and establish acceptable behaviors, offer choices and optimism (option of taking medication), debrief the patient and the staff.

What Mediators Can Teach Physicians About Managing ‘Difficult’ Patients – The American Journal of Medicine, Editorial: view difficult patients as syndromes, not a species. Situation is volatile: escalation or de-escalation is seconds away, calling someone out for bad behavior makes matters worse, exercise neutrality, name the concern to create alliance and avoid adversity, apologize.

Medications

First generation: haloperidol & droperidol. Droperidol: recent annals article using 10mg with no complications. Haldol is black-box as well right now

Second generation: olanzapine, ziprasizone, aripirazole, oral only (risperidone, quetiapine).

IV Olanzapine (Zyprexa): as effective as IV halidol. Similiar history as FDA approved for IM, though not IV. Few studies, less SE compared to haldol. Start at 2.5mg-5mg, max daily dose of 20mg. Higher doses have higher risk of sedation. (Martel 2015)

Benzos (dia/lora/clonea)

Ketamine. Dosing 40-400mg IM, 50-200mg IV. No over-sedation, 2/3 required additional doses.

References

Agitated, Psychotic, and Strong, Stephen Schenkel, The Crashing Patient Conference 2015.

Intravenous Olanzapine: Faster than IM Olanzapine, safer than IV haloperidol, Josh Farkas, PulmCrit

285. Psychotropic Medications and Rapid Tranquilization