1. Managing Alcohol and Opioid Withdrawals
Pouneh Nasseri MD
Chief resident

2. Goals of lecture
Recognize alcohol and opioid withdrawal in the inpatient setting
Management of withdrawal in the inpatient setting

3. Alcohol use terminology
Standard drink Approximate # of standard drinks in:
Equivalents:

4. Recognizing alcoholism
Terms used: alcohol abuse, alcohol dependence, alcohol use disorder
Typical characteristics
Impaired control over drinking
Preoccupation with alcohol
Use of alcohol despite adverse consequences
Distortions in thinking, most notably denial
Different screening tools:
CAGE
Alcohol use disorder identification Test (AUDIT) or AUDIT-C
AUDIT
AUDIT C
CAGE

5. How many drinks are too many?
The National Institute on Alcohol Abuse and Alcoholism (NIAAA) definition:
Men under age 65
More than 14 standard drinks per week on average
More than 4 drinks on any day
Women, adults 65 years and older
More than 7 standard drinks per week on average
More than 3 drinks on any day
amounts of alcohol that increase health risks

6. Alcohol Withdrawal Pathophysiology
ETOH = Depressant
Sudden cessation causes CNS hyperactivity
Enhances inhibitory tone (via modulation of gamma-aminobutyric acid activity)
Inhibits excitatory tone (via modulation of excitatory amino acid activity).
GABA is a inhibitory system in CNS
Chronic ethanol use induces an insensitivity to GABA such that more inhibitor is required to maintain a constant inhibitory tone . As alcohol tolerance develops, the individual retains arousal at concentrations which would normally produce lethargy or even coma.

7. Alcohol withdrawal symptoms
MINOR WITHDRAWAL SYMPTOMS 
Insomnia
Tremulousness
Mild anxiety
Gastrointestinal upset
Headache
Diaphoresis
Palpitations
Can treat in the outpatient setting

8. Alcohol Withdrawal
Gamma aminibutyric acid GABA

9. ETOH Withdrawal and timeline
-seizures occur predominantly in patients with a long history of chronic alcoholism. Can show up from 2 hours and when patient still has ETOH level
-Alcoholic hallucinosis refers to hallucinations that develop within 12 to 24 hours of abstinence and resolve within 24 to 48 hours .
- Hallucinations are usually visual, although auditory and tactile phenomena may also occur. In contrast to delirium tremens, alcoholic hallucinosis is not associated with global clouding of the sensorium, but with specific hallucinations, and vital signs are usually normal

10. Delirium Tremens
Defined as: Hallucinations, disorientation, altered mental status, tachycardia, hypertension, fever, agitation, and diaphoresis
Can start from hours from last drink
Could last from 1-7 days
Mortality of 5%
-Death usually is due to arrhythmia, complicating illnesses, such as pneumonia, or failure to identify an underlying problem that led to the cessation of alcohol use, such as pancreatitis, hepatitis, or central nervous system injury or infection. Older age, preexisting pulmonary disease, core body temperature greater than 40ºC (104ºF), and coexisting liver disease are associated with a greater risk of mortality

11. Risk factors for Delirium Tremens
History of DT
Age > 30
Longer period of drinking
Multiple medical illness
Significant alcohol withdrawal despite high ETOH level
A longer period since the last drink

12. Management of ETOH Withdrawal
Alleviating symptoms of psychomotor agitation
Volume deficit replacement: Hypovolemic
Correcting metabolic derangements
Electrolyte imbalance : Potassium, Magnesium , Phosphorous
Ketoacidosis
Vitamin deficiencies: Wernicke’s encephalopathy. Give Thiamine with glucose.
Protein calorie malnutrition
Hypovolemic: diaphoresis, hyperthermia, vomiting, and tachypnea
Hypokalemia is common due to renal and extrarenal losses, alterations in aldosterone levels, and changes in potassium distribution across the cell membrane
Hypomagnesemia is common in patients with DT and may predispose to dysrhythmia and seizures
Hypophosphatemia may occur due to malnutrition, may be symptomatic, and if severe, may contribute to cardiac failure and rhabdomyolysis

13. Supportive care
GI absorption can be impaired so using IV in the first 2 days is helpful
Banana bag: D5NS with thiamine, folate, and a multivitamin
If intoxicated and severe withdrawal consider NPO initially to avoid aspiration

14. Treatment of psychomotor agitation CIWA- Ar
Nausea/Vomiting (0-7)
Headache(0-7)
Paroxysmal sweating (0-7)
Anxiety (0-7)
Auditory disturbances (0-7)
Visual disturbances (0-7)
Agitation (0-7)
Tremor (0-7)
Tactile Disturbances (0-7)
Orientation and clouding of sensorium (0-4)

15. CIWA-Ar Symptom triggered therapy Start treatment at CIWA score > 8
< 10 : Very Mild withdrawal
10-15: Mild withdrawal
16-20: Modest withdrawal
>20 : severe withdrawal
Start treatment at CIWA score > 8
Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWAS-Ar), a measure of withdrawal severity

16. Benzodiazepines Diazepam (Valium) 5-10 mg IV every 5-10min
Lorazepam (Ativan ) 2-4 mg IV every min
Chlordiazepoxide (Librium) (should be used in PPX)
Should be given IV in modest-severe withdrawal
Dosing: depends on comorbid conditions
Diazepam: longer acting with active matobolites
Lorazepam: shorter acting better with liver disease
Librium should be avoided in all cirrhotic patients

17. Prophylaxis
Consider PPX in asymptomatic patients who have high risk factors for DT and withdrawal.
Librium taper: 50 to 100 mg POq6hrs for one day and then 25 to 50 mg Q6hrs for 2 days.
Can use Librium for very mild withdrawal in low risk patient mg PO as needed Q1hrs.

18. Other treatments Ethanol Antipsychotics (such as Haldol)
Anticonvulsants ( such as phenobarbital, Carbamazepine)
Centrally acting alpha-2 (Such as Clonidine)
Beta blockers (Such as Propranolol)
Baclofen
These agents are less well studied than benzodiazepines and may mask the hemodynamic signs of withdrawal, which can precede seizures.
Ethanol: difficult to titrate
Haldol: decreases seizure threshold . Plus prolong QT given all the electrolyte abnormalities
Phenobarb can be used in conjunction with benzos in ICU setting but not alone
Carbamazepine can sometimes be used in mild but not in inpatient settting
Clonidine no evidence that helps reduce DT or seizures. Not enough evidence
Beta blocker is the same as alpha
Baclofen does bind to GABA but no evidence of controlling severe symptoms

19. ICU admission

20. Opioid Withdrawal
Sign and symptoms can start within 6-12 hour after short acting opioid and hrs after Methadone
History can help you diagnose.
Severity of symptoms depends of duration, dose of opioid and if there is a iatrogenic withdrawal

21. Opioid withdrawal Natural opioid withdrawal is not life threating
Iatrogenic withdrawal can be dangerous:
reversal agent such as Naloxone or naltrexone can produce sudden surges in catecholamines and hemodynamic instability

22. Opioid withdrawal

24. Opioid withdrawal Opioid agonist therapy: if they missed a dose or two
Methadone 10 mg IM or Methadone 20 mg PO if they can tolerate PO

25. Opioid withdrawal Non-opioid adjunctive medications
Alpha 2 antagonist Clonidine: 0.1 to 0.3 mg every hour as needed
Benzodiazepine: Diazepam mg IV q5-15min PRN
Phenegran: 25 mg IV or PO
Loperamide
Octerotide
- Binds to a central alpha 2 adrenergic receptor that shares potassium channels with opioids, and blunts symptoms of withdrawal. Look for hypotension
-Benzos: GABAergic drugs reduce catecholamine release during severe withdrawal. helpful in suppressing muscle cramps. -