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Treatment of Alcoholism and Addiction

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Presentation on theme: "Treatment of Alcoholism and Addiction"— Presentation transcript:

1 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

2 Addiction Reward Pathway

3 Admission Labs Labs (BAL, CBC, Chem 22, Mg, TSH, RPR, lipase, UDS, UA, pregnancy test) PPD CXR EKG Acetaminophen and salicilate level as indicated

4 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

5 Alcohol Breakdown Alcohol ADH Acetaldehyde ALDH Acetic acid and water

6 Alcohol Intoxication 20-99mg% loss of muscular coordination, change in behavior mg% ataxia, mental impairment mg% obvious intoxication, nausea and vomiting mg% severe dysarthria and amnesia

7 Alcohol Intoxication cont.
mg% coma occurs mg% decreased respirations and blood pressure, obtundation, often fatal Important to remember the role of tolerance in all these categories

8 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

9 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

10 Withdrawal Signs and Symptoms
Tremor Agitation Autonomic changes (BP, HR, Temp.) Seizures Sensorium changes (eg, hallucinations, confusion)

11 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.

12 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

13 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

14 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

15 Detox Pharmacology Benzodiazepine and Barbiturate equivalents:
Diazepam 10mg Lorazepam 2mg Phenobarbital 30mg Chlordiazepoxide 25mg Oxazepam 30mg

16 Detox Pharmacotherapy
Know 2-3 drugs well for routine detox (e.g., Diazepam 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.

17 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

18 Alcohol Withdrawal Seizures
Mostly Grand mal seizures Usually 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

19 GABA and NMDA Neuronal Receptors
Substance Abuse, J Lowinson, MD. Third Edition, 1997, page 129.

20 Kindling and Seizures

21 Alcohol Withdrawal Seizure Treatment
Parenteral benzodiazepines (eg, ativan 2 mg or valium 10 mg iv stat) Seizure precautions Valium 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

22 Pharmacotherapy Treatment
Disulfiram Naltrexone Acamprosate

23 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

24 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

25 Naltrexone Opiate blocker
Evidence for reduced cravings and relapse rates 23% relapsed vs. 54% placebo during 12 week study Definition of relapse Volpicelli, 1992

26 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 Krystal, et al. NEJM Volume 345, pg , Dec 13, 2001

27 Acamprosate Affinity for GABA A and GABA B receptors
Inhibits glutamate effect on NMDA receptors Now available in the United States

28 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

29 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

30 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 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

31 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

32 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.

33 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

34 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

35 Opioid Dependence Physiologic dependence versus addiction
Common opioids Rx drugs on the streets, etc. Abuse patterns

36 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

37 Opioid Treatment Clonidine 0.1 mg every 2 hours prn
Benzodiazepine or barbiturate prn (eg, Phenobarbital mg every 3 hours prn) NSAID Muscle relaxant (eg, methacarbamol) Bentyl for abdominal cramps Sleeping agent (eg, temazepam)

38 Opioid Treatment (cont.)
Subutex (buprenorphine) Suboxone (buprenorphine/naloxone) Sublingual administration of partial opioid agonist Must be certified through DEA to use

39 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

40 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

41 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

42 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

43 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)

44 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

45 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

46 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

47 Nicotine Fagerstrom Test Nicotine Replacement (gum, patches) Bupropion
Support Groups

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