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Treatment of Alcoholism and Addiction

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Metabolized primarily in the liver by oxidation ... 45 y.o. female taking increasing doses of hydrocodone per day. Currently on 90 mg per day ... – PowerPoint PPT presentation

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Title: Treatment of Alcoholism and Addiction


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 A
    LDH 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 benzos 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
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 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

26
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 AMAs 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
  • Dont 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, benzos 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 MDs
    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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