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Goals. Review manifestations of withdrawal syndromesAssess risk and severity of w/dStrategies to optimize therapyReview SFGH Guidelines. Challenges of AWS Management. Under-treatment? Use of restraints, dangerous situationsProgression to DTs, higher mortalityOver-treatmentBenzodiazepine intoxication, deliriumSedation, aspiration, intubationInappropriate BZD choice and dosingWrong diagnosis or missed co-morbid condition.
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1. Management of AcuteAlcohol & Opiate Withdrawal Todd A. May, M.D.
Director, Family Medicine Inpatient Service
San Francisco General Hospital
Clinical Professor
Department of Family & Community Medicine
University of California, San Francisco
2. Goals Review manifestations of withdrawal syndromes
Assess risk and severity of w/d
Strategies to optimize therapy
Review SFGH Guidelines
3. Challenges of AWS Management Under-treatment
? Use of restraints, dangerous situations
Progression to DTs, higher mortality
Over-treatment
Benzodiazepine intoxication, delirium
Sedation, aspiration, intubation
Inappropriate BZD choice and dosing
Wrong diagnosis or missed co-morbid condition
4. Alcohol Withdrawal Syndrome Symptoms
anxiety
insomnia
tremulousness
headache
nausea Signs
tremor
diaphoresis
agitation
tachycardia
hypertension
low grade fever (<38.5)
5. Withdrawal Seizures Generalized, non-focal
Seizure onset < 48 hours after cessation
May recur; status epilepticus rare
Look for other etiology if:
onset > 48 hours
focal seizures
fever or head trauma
6. Alcohol Hallucinosis Early onset12 to 24 hours after cessation
Able to maintain clear sensorium
Resolves in 24 to 48 hours
7. Alcohol Withdrawal Delirium (DTs) Onset 48 - 96 hours after cessation
Usually following prolonged, heavy drinking
Clouding of consciousness
Delirium
8. Alcohol Withdrawal Delirium (DTs) Delirium
impaired attention/concentration
disorientation
waxing/waning level of consciousness
hallucinations visual > tactile >> auditory
delusions
9. If delirium persists or atypical features, consider:
Infection
CNS event (e.g., subdural hematoma)
Metabolic disturbance
Hepatic encephalopathy
Wernickes encephalopathy
BZD intoxication
Psychiatric disorder Alcohol Withdrawal Delirium (DTs)
11. Assessing Risk of AWS Frequency, amount, time of last drink
H/O w/d; needing meds for detox
H/O seizures, hallucinosis, or DTs
Concurrent substance use
Comorbid illness
12. Assessing Risk of AWS Prior w/d history is strongest predictor
Mild risk
self-limited w/d symptoms
Moderate risk
w/d requiring medications
Severe risk
w/d seizure or delirium
14. CIWA-Ar Nausea, vomiting
Tremor
Sweats
Anxiety
Agitation Tactile disturbance
Auditory disturbance
Visual disturbance
Headache
Orientation/clouding of sensorium
15. CIWA Developed, studied extensively 1980s
Originally 18 items ? 10
Imported to various settings
Detox units
Psychiatric units
Medical-surgical wards
16. CIWA CIWA score predicts (in detox units)
Severe w/d symptoms, seizures, delirium
Naranjo Clin Pharm Therap 1983;34:214-19
Hospitalized medical patients
CIWA > 15 predicts severe w/d and delirium
RR 3.72 (95% CI 2.85-4.85)
Foy Alc Clin Exp Res 1988;12:360-64
17. Assessing Severity of AWS Clinical Institute Withdrawal Assessment for Alcohol, revised (CIWA-Ar)
Reliable, validated assessment tool
Brief, easy to use
Score correlates with severity of w/d
Enhances communication between staff
Can guide management decisions
Recommended by ASAM
18. CIWA-Ar Caveats
Not diagnostic
Assessment tool only
Must interpret score in clinical context
Co-morbid illness can confound the scoring
Bottom line: Interpret--dont just treat a number
Work together with the nurses
19. CIWA-Ar Score 8-15 Mild
Score 16-25 Moderate
Score > 25 Severe
21. Management of AWS General Measures
Seizure precautions with h/o Sz
Hydration
Thiamine 100mg IM/IV prior to glucose
Correct electrolytesMg, Ca, K, PO4
Treat concurrent illnesses
22. Management of AWS
Which drug?
What route?
How to dose?
23. Management of AWS Benzodiazepines (BDZ)
Treatment of choice
Clearly reduce symptoms and ? risk of Sz (-4.9/100 pt), delirium (-7.7/100 pt)
Phenobarbital
Narrow therapeutic index
Carbamazepine
Effective alternative, less sedation
24. Choice of Benzodiazepine All seem effective for AWS
Limited comparative data
All metabolized by liver
Differences
Onset of action, half life, routes
1 or 2 step metabolism; active metabolites
Long vs shorter acting
25. Long-acting BDZs Chlordiazepoxide (Librium)
Oral dosing only
Intermediate onset
Long-acting parent compound and metabolites
Smoother withdrawal, less sz, better cognitive fxn
Potential accumulation in elderly and patients with liver disease
[Diazepam]
26. Shorter-acting BDZs Lorazepam (Ativan)
Versatile dosingPO, IV, IM, SL
Fast to intermediate onset
Intermediate half-life, no metabolites
Less likely to accumulate in elderly or with liver disease
Breakthrough sx, met. acidosis, delirium
[Oxazepam]
27. Benzodiazepines Chlordiazepoxide generally preferred
Indications for Lorazepam
Elderly
Established liver disease
NPO
Severe w/d requiring frequent or high doses
28. Benzodiazepines Route of administration
Oral preferable
Ease of administration
More consistent blood levels
Sublingual if NPO
(e.g., surgical patients)
Intravenous
Severe w/d requiring rapid titration or NPO
29. Benzodiazepines--Dosing Options Fixed Schedule Regimens
Traditional approach
Administer BZD around the clock
Additional doses prn
Taper by 25% per day when stable
Risk for under-dosing, over-sedation, drug accumulation
30. Benzodiazepines--Dosing Options
32. Symptom-triggered vs. fixed dose
33. Symptom-triggered therapy 101 patients, VA inpatient detox center
Randomized, double-blind STT vs fixed dose schedule with chlordiazepoxide
Results
Lower total BDZ: 100mg vs 425mg (p<0.01)
Shorter duration: 9h vs 68hr (p<0.01)
Trend: ? severity, Sz, DTs
34. Symptom-triggered therapy 216 Medical inpatients
Retrospective, pre-/post-intervention
Results
*Delirium: 21 ? 7% (p=0.04)*
Total BDZ equiv: 20 ? 20 (p=0.38)
Duration: 56hr ? 45hr (p=0.16)
Complications: 33 ? 18% (NS)
Mortality: 2.4% ? 0 (NS)
35. Symptom-triggered therapy Medical inpatients
No RCTs of STT vs. fixed dosing
(no RCTs for fixed dosing either)
Many observational and retrospective studies with a variety of BDZ
General: STT as effective or better
Variable ? severity, LOS, total med, DTs, etc
Makes sense; Growing trend worldwide; Beware of pitfalls and limitations
36. SFGH Guidelines Three Clinical Scenarios
Risk, but no active w/d
Mild-moderate w/d
Severe w/d
3 Pre-printed order forms
37. Risk for Withdrawal (CIWA <8) Observation only
No prior h/o w/d or not actively drinking
Severe or decompensated liver disease
Order: CIWA q 6hr, call HO > 8
Prophylaxis
Use only if h/o w/d
Select drug based on patient profile
Select dosing taper based on severity of hx
38. Mild-Mod Withdrawal (CIWA 8-25) Symptom-triggered therapy
Select drug based on patient profile
Sliding scale STT strategy
Select drug, not dose
Reassess periodically for adequacy of symptom control or over-sedation
39. Mild-Mod Withdrawal (CIWA 8-25)
40. Severe Withdrawal (CIWA>25) Urgent, serious, unstable situation
Abandon CIWA; goal sedation score of 3
Lorazepam IV bolus q15-30min prn
Haloperidol for agitation when autonomic symptoms controlled
Avoid Lorazepam infusion if possible
Infusion management tips
41. AWS Summary Become familiar with CIWA scale
Assess risk for w/d
Choose BDZ based on pt profile
Symptom-triggered therapy, usually
Individualize treatment, reassess
Minimize IV drips
Adjunctive Haloperidol for delirium
42. Opiate Withdrawal Very uncomfortable
Not life-threatening, in contrast to alcohol withdrawal
Concurrent medical problems and medications can complicate treatment
43. Opiate Withdrawal Symptoms
Anxiety
Insomnia
Abd pain/cramps
Rhinorrhea
Lacrimation
Yawning
N/V/D Signs
Dilated pupils
Diaphoresis
Piloerection
No seizures, tremor, DTs
44. Opiate Withdrawal
W/D Heroin Methadone
Onset 12-24hr 1-3d
Peak 2-3d 5-7d
Duration 5-7d 14-21d
46. Methadone Treatment On methadone maintenance
Confirm outpatient dose with clinic
Continue outpatient dose
Do not split dose or increase to treat pain
47. Methadone Treatment--Initial Not on methadone; dose unconfirmed
Give 10-20mg once
Evaluate in 4-8hr for sedation or persistent w/d signs, symptoms
Give additional 10-20mg if needed
Usually need =40-60mg/24h
Order adjunctive medications
48. Methadone Treatment--subsequent Evaluate for w/d daily
If w/d present and no sedation, may increase daily dose by 10-20mg
Must evaluate for sedation 4-8hr after dose increase
Taper by ~5mg/d, as tolerated, when symptoms controlled
49. Alternative/Adjunctive Treatment Clonidine
Non-opioid treatment of noradrenergic-activated neuronal activity
Decreases severity of w/d symptoms
Acutely titrate to symptoms, taper after day 3
Clonidine 0.1mg q4h prn symptoms (write BP parameter)
50. Adjunctive Treatment Helpful in safely controlling symptoms
Hydroxyzine 25-50mg q6h prn anxiety/insomnia
Ibuprofen 400-800mg q6h prn pain
Trazadone 50-100mg bedtime prn insomnia
Loperamide ii tab (2mg ea) initially, then i tab prn diarrhea, NTE 16mg/d
51. Pain Management & Methadone Once daily methadone for opiate dependencedispensed by licensed clinics only
Divided dose can be used for chronic pain
Patients on methadone with acute pain:
Continue outpt methadone dosing
Prevent opiate w/d
Avoid substantial change in outpt regimen
Choose alternative opioid for acute pain control
52. Methadone Do NOT:
Split usual once daily methadone dose
Give initial (unconfirmed) dose >30mg
Use methadone for both opiate dependence and pain control
Write prn orders for methadone
53. Methadone: drug interactions Increase metabolism (?methadone effect)
Phenytoin, carbamazepine
Protease inhibitors, Efavirenz, Nevirapine
Rifampin
Decrease metabolism (? effect)
Benzodiazepines
Quinolones
54. Discharge Planning Assess patients interest in long-term Rx early (plan ahead)
Patients options:
Continue drug use
Short-course detox while hospitalized
30d detox or methadone maintenance at Ward 93
Plan inpatient management accordingly
Dont Rx with constant dose and d/c without plan
55. Buprenorphine Opioid agonist and partial antagonist
Can be prescribed in office practice
Cannot be started at SFGH while inpatient
Patients admitted on maintenance
Continue confirmed outpatient dose
Mild-mod pain: NSAIDs, codeine, hydrocodone
Severe pain: stop buprenorphine, use morphine or other potent narcotic analgesic
See CHN guidelines; Pain Management consult recommended
56.
Todd May
Office: 4F43
Phone: 206-5786
Pager: 443-9702