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Treatment of Alcoholism and Addiction Steven R. Ey, M.D. Medical Director Genesis Chemical Dependency Unit South Coast Medical Center Laguna Beach, CA.

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Presentation on theme: "Treatment of Alcoholism and Addiction Steven R. Ey, M.D. Medical Director Genesis Chemical Dependency Unit South Coast Medical Center Laguna Beach, CA."— 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  AlcoholADH Acetaldehyde ALDH Acetic acid and water

6 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

7 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

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 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.

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 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

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

20 Kindling and Seizures

21 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 1 st 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 Volpicelli, 1992 Naltrexone  Opiate blocker  Evidence for reduced cravings and relapse rates  23% relapsed vs. 54% placebo during 12 week study  Definition of relapse

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

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 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

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 15-30 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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