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Addiction Issues in Critical Care

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Title: Addiction Issues in Critical Care


1
Addiction Issues in Critical Care
  • Kevin Kunz M.D.,M.P.H.,FASAM

2
Overview of Todays Talk
  • Addiction What is it?
  • Complications of addiction
  • Treatment of overdose and withdrawal
  • Alcohol
  • Opioids
  • Methamphetamine

3
The United States of Drugs
4
Addiction
  • Addiction is a primary, chronic, neurobiologic
    disease, with genetic, psychosocial, and
    environmental factors influencing its development
    and manifestations.

5
Addiction The 5 Cs
  • Control of drug use is lost
  • Consequences of use
  • Continued use despite consequences
  • Craving
  • Compulsive use

6
Physical Dependence or Addiction?
  • Physical dependence is a normal physiologic
    response to the medical use of certain drugs
  • Addiction involves the non-medical use of drugs

7
Preventable Causes of death

8
Total attributed
Tobacco Deaths
  • 530,000 Deaths / Year
  • 23 of all Deaths
  • 38 of all Cancer Deaths
  • 24 Cardiovascular Deaths
  • 40 Respiratory Deaths
  • Etc. Etc.

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Mesolimbic pathway
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Alcohol Withdrawal Syndrome
  • EtOh is a CNS depressant
  • Enhances GABA effect
  • Sedation, muscle relaxation, raised seizure
    threshold
  • Inhibits autonomic adrenergic systems
  • Particularly in the locus ceruleus
  • EtoH decrease or abstinence causes rebound
  • Relative GABA deficiency leads to anxiety,
    increased psychomotor activity, seizure kindling
  • Rebound sympathetic adrenergic activity leads to
    tachycardia, HBP, tremor, diaphoresis

26
Alcohol Overdose and Withdrawal
  • .

27
Alcohol Overdose
  • .02-.1mg mood, personality, behavior changes,
    loss of muscle coordination
  • .1-.2 mg prolonged reaction time, ataxia,
    in-coordination, mental/neurologic deficits
  • .2-.4 mg obvious intoxication, nausea, vomiting,
    hypothermia,dysarthria, amnesia
  • .4-.8mg coma
  • .6-.8 mg death
  • Treatment Supportive only, no known antagonist

28
Subtypes of Alcohol Withdrawal A,B,C
  • Each type may present alone, or with others
  • Each type is variable in intensity
  • Type A GABA receptor associated, symptoms
    similar to a hangover
  • Type B Hyperadrenergic, a physiologic,
    metabolic rebound/rush
  • Type C mesolimbic/dopaminergic, cognitive
    changes, psychosis, delirium

29
AWS Type A
  • Type A GABA associated
  • Uneasiness, Sense of foreboding
  • Motor hyperactivity
  • Dysphoria, lability of mood
  • Sensitivity/reaction to abrupt sensory stimuli
  • Anxiety, Insomnia
  • Treatment of Type A withdrawal?
  • A GABA agonist
  • Benzodiazepines
  • Barbiturate
  • AEDs ( gabapentin, others)

30
Type A Treatment Caveats
  • Tendency to use benzopiazepines (BNZ) in too low,
    or too high a dose
  • Librium and Valium contraindicated in liver
    disease use Ativan
  • Potential adverse effects may complicate and
    prolong withdrawal
  • BNZ and barbiturates may cause ataxia,
    over-sedation, respiratory depression,
    disinhibition, cognitive disruption

31
AWS - Type B
  • Type B adrenergic rebound
  • Tachycardia, palpitations
  • Hypertension
  • Chills, diaphoresis
  • Fever, hypermetabolic state
  • Pilo-erection, mydriasis
  • Nausea/vomiting/diarrhea
  • Treatment of Type B withdrawal?
  • Alpha and beta adrenergic blocking agents
  • (clonidine, propanolol, atenolol, others)

32
Type B Treatment Caveats
  • Beta Blockers
  • Contraindications
  • Volume depletion, asthma/COPD, CHF, sick sinus
    syndrome, high-grade conduction blocks
  • Potential Adverse Effects
  • Hypotension, bradycardia, bronchospasm
  • Alpha Blockers
  • Contraindications
  • As above except asthma/COPD
  • Potential Adverse Effects
  • Hypotension, bradycardia, confusion (rare)

33
AWS Type C
  • Type C mesolimbic/dopaminergic
  • Attention deficit, disorientation
  • Hyper-alertness, psychomotor agitation
  • Impaired short-term memory and reasoning
  • Visual and auditory hallucinations
  • Delirium
  • Treatment of Type C withdrawal?
  • Neuroleptics
  • (Haldol, droperidol, Risperdal, Zyprexa)

34
Delirium and Delirium Tremens
  • delirium can occur with or without the tremens
  • tremens refers to the extreme Type B
    withdrawal signs and symptoms
  • appears 3-4 days after the last drink
  • continues an average of 2-3 days, with a range
    from a few hours to over 30 days

35
Classic Delirium
  • Tom Sawyer described it in his father
  • Incidence of 5 in hospitalized AWS pts
  • Abrupt onset is usual
  • Global confusion and disorientation
  • Patient in a separate psychic reality
  • Auditory and visual hallucinations
  • No insight to condition, can be frightening
  • Agitation, increased psychomotor activity common
  • Disturbed sleep cycle

36
Risk Factors for Delirium
  • Often no identifiable risk factor other than
    decrease/abstinence of alcohol
  • Poor Correlation Duration of heavy drinking and
    amount of daily intake
  • High blood alcohol on admission (greater than
    300mg/dl)
  • Age
  • Co-morbidity
  • GI Bleed,trauma,Hx of past AWS,malnutrition,
    concurrent drug use, etc.

37
Type C Treatment Caveats
  • Haldol, Droperidol
  • Contraindications
  • Prolonged QT interval, Parkinsons, hypotension
  • Potential Adverse Effects
  • Heavy sedation, dystonic reactions, Parkinsonian
    crisis, neuroleptic malignant syndrome,
    pro-convulsant
  • Risperdal, Zyprexa
  • Relative Contraindication cost
  • Potential Adverse Effects
  • Pro-convulsant, at high dose may exacerbate
    pre-existing psychotic disorder

38
Delirium Rx in Kona
  • Haldol 2.5 5mg IV q 4H prn
  • Benadryl 25-50mg/d to prevent dystonia
  • Ativan (Valium if liver OK), IV q 2-4 hours prn
  • Pentobarbital protocol if Haldol fails
  • Sublinqual atypical neuroleptics now being used
    in some settings
  • Hydration, monitoring and correction of
    lytes/minerals, restraints when needed
  • Minimize dose of all meds, make patient
    comfortable, conscious sedation not necessary

39
Other EtOh Related Neurologic Disorders
  • Intermediate Brain Syndrome
  • Wernickes Encephalopathy
  • Korsakoffs Psychosis
  • Alcoholic Dementia
  • Alcoholic Cerebellar Degeneration
  • Alcoholic Polynauropathy
  • Central Pontine Myelinolysis

40
Central Pontine Myelinolysis
  • Edema of the pons, caused by sudden/quick
    correction of hyponatremia
  • Dysarthria
  • Dysphagia
  • Rapid onset paraparesis or quadriparesis

41
Wernicke Korsakoff
  • Wernickes Disease
  • Caused by thiamine deficiency
  • Diagnostic triad mental disturbance (apathy,
    confusion, etc), sixth nerve palsy (and
    nystagmus), ataxia
  • Delay in treatment risks permanent damage
  • Korsakoffs Psychosis
  • Profound deficit in retentive memory, learning
  • Intelligence and verbal abilities preserved
  • Confabulation
  • Often follows Wernickes Disease

42
Thiamine and Wernicke-Korsakoff
  • Thiamine 100mg IV to every EtOhic ASAP
  • Give thiamine before glucose solution
  • Then give thiamine 100 mg daily IV or PO
  • Thiamine is used to prevent Wernickes disease,
    and to treat Korsakoffs psychosis

43
Seizures
  • Seizures reported in 11-35 of patients
    withdrawing from EtOh in hospital setting
  • Usually grand mal and single, or a burst of
    several over 1-6 hours
  • Always rule-out other causes subdural,
    stimulant (and tramadol) induced not uncommon
  • Phenytoin is not prophylactic, and not indicated
    for Rx - use BNZ

44
Common AWS Treatment Errors
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46
National plane crash
Imagine 3 full jumbo jets crashing to the earth
daily. That is the number of lives we lose to
tobacco each day.
C. Everett Koop M.D. Surgeon General 1981-1989
47
CVA
  • 25 of all Strokes

48
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Heroin ad
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.opioid receptor model
  • .

51
Receptor Mediated Actions
  • Mu
  • Supraspinal analgesia
  • Respiratory depression
  • GI stasis
  • Urinary retention
  • Bradycardia
  • Euphoria
  • Pruritis
  • Physical dependence
  • Kappa
  • Supraspinal analgesia, sedation, miosis,
    hyperalgesia
  • Sigma
  • Dysphoria, hallucinations, hypertonia,
    tachycardia, tachypnea

52
Opioid Drug Classes
  • Agonist
  • Relieve pain and alter mood
  • Antagonist
  • Displace or block opioids from receptors, no mood
    altering effect
  • Mixed agonist/antagonist
  • Have both agonist and antagonist actions

53
.morphine molecule
  • .

54
Opioid Adverse Effects
  • Sedation
  • Respiratory depression
  • Nausea, vomiting, sweating
  • Constipation (no tolerance)
  • Miosis (no tolerance)
  • Truncal rigidity
  • Hypotension
  • Histamine release
  • GI effects decreases HCl, secretions, propulsive
    waves sphincter of Oddi spasm
  • Inhibition of urinary voiding reflex
  • Tolerance, dependence, addiction(rare)

55
Antagonists
  • Naloxone (Narcan)
  • Naltrexone ( Trexan, Revia)
  • Nalmefene ( Revex)

56
Opioid Overdose
  • Pinpoint pupils (later dilated)
  • Respiratory depression
  • Coma

57
Opioid Adverse Effects
  • Sedation
  • Respiratory depression
  • Nausea, vomiting, sweating
  • Constipation (no tolerance)
  • Miosis (no tolerance)
  • Truncal rigidity
  • Hypotension
  • Histamine release
  • GI effects decreases HCl, secretions, propulsive
    waves sphincter of Oddi spasm
  • Inhibition of urinary voiding reflex
  • Tolerance, dependence, addiction(rare)

58
Opioid Overdose
  • Pinpoint pupils (later dilated)
  • Respiratory depression
  • Coma

59
Rx for Opioid Overdose
  • Airway and ventilation
  • Opioid antagonist (Narcan)
  • Dilute .4 mg in 10cc saline, titrate to effect
  • Be alert to rebound sympathetic response
    arrhythmias, pulm. Edema
  • Can precipitate major withdrawal syndrome

60
Topics of Discussion
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61
Topic One
  • Details about this topic
  • Supporting information and examples
  • How it relates to your audience

62
Topic Two
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63
Topic Three
  • Details about this topic
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  • How it relates to your audience

64
Real Life
  • Give an example or real life anecdote
  • Sympathize with the audiences situation if
    appropriate

65
What This Means
  • Add a strong statement that summarizes how you
    feel or think about this topic
  • Summarize key points you want your audience to
    remember

66
Next Steps
  • Summarize any actions required of your audience
  • Summarize any follow up action items required of
    you
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