Withdrawal.

Transcription

1 Withdrawal Shamim Nejad, MD Director, Adult Burns & Trauma Psychiatry Division of Psychiatry and Medicine Medical Director, Addiction Consultation Team MGH Center for Addiction Medicine Massachusetts General Hospital Assistant Professor of Psychiatry Harvard Medical School

2 Disclosures: Shamim Nejad, MD Neither I nor my spouse/partner has a relevant financial relationship with a commercial interest to disclose.

3 Withdrawal: Overview Epidemiology Uncomplicated alcohol withdrawal syndrome (AWS) Signs and symptom Management strategies Opioid withdrawal syndrome Signs and symptoms Management strategies

4 Epidemiology of AUD Alcohol use disorder (AUD) in the US: Adults (ages 18+): 16.6 million adults ages 18 and older had an AUD in This includes 10.8 million men and 5.8 million women. About 1.3 million adults received treatment for an AUD at a specialized facility in 2013 (7.8 percent of adults who needed treatment). This included 904,000 million men. Youth (ages 12 17): In 2013 an estimated 697,000 adolescents ages had an AUD. This number includes 385,000 women and 311,000 men. An estimated 73,000 adolescents (44,000 males and 29,000 females) received treatment for an alcohol problem in a specialized facility in

5 Epidemiology: AWS Prevalence of alcohol withdrawal is less than 5% in general population Prevalence of alcohol withdrawal is approximately 86% in detoxification centers and rehab facilities In one study, 94% of patients deemed suitable for outpatient management of AWS successfully completed detoxification in this setting. Caetano R, Clark CL, Greenfield TK. Prevalence, trends, and incidence of alcohol withdrawal symptoms: analysis of general population and clinical samples. Alcohol Health Res World 1998;22:73 9. Soyka M, Horak M. Outpatient alcohol detoxification: implementation efficacy and outcome effectiveness of a model project. Eur Addict Res 2004;10:180 7.

6 DSM-5 Criteria for Alcohol Withdrawal Cessation or reduction in alcohol use, especially after a period of heavy and prolonged drinking, result in alcohol withdrawal. The symptoms of alcohol withdrawal syndrome develop within several hours to a few days after an individual stops drinking. These can include: Insomnia (trouble sleeping) Autonomic symptoms (including, sweating or racing heart) Increased hand tremors (known as the shakes ) Nausea and/or vomiting Psychomotor agitation (feeling physically restless, inability to stop moving) Anxiety Seizures (typically the generalized tonic-clonic type, which is characterized by rhythmic, yet jerking movement, especially of the limbs) Hallucinations, or perceptual disturbances of the auditory, tactile, or visual type (the rarest of alcohol withdrawal symptoms) In order to meet the DSM-5 criteria for alcohol withdrawal syndrome, a person must experience a combination of two of more of these symptoms. Significant distress or impairment in social, occupational, or other important areas of functioning must also be present. These symptoms must be directly caused by stopping or reducing alcohol intake and not attributable to other medical conditions, a primary mental disorder, or the influence of another substance.

7 Clinical States of Alcohol Withdrawal 4 main clinical states: Autonomic hyperactivity Neuronal excitation Hallucinations (+/- paranoid state) Alcohol withdrawal delirium (delirium tremens)

8 Phenotypes of AWS Stages Clinical Findings Onset (Usual * ) Early or Uncomplicated 1) Anxiety, fine tremor (anxiety), tachycardia (anxiety); headache; palpitations; anorexia; GI upset; general malaise 2) May have elements of catacholamine excess (coarse tremor, elevated BP, elevated HR, diaphoresis, slight fever) 6-36 hrs Phenotype of AWS Uncomplicated Complicated Seizure Generalized, tonic-clonic seizures, status epilepticus (rare) 6-48 hrs Alcoholic Hallucinosis Visual, auditory, and/or tactile hallucinations hrs Delirium Tremens Delirium, tachycardia, hypertension, agitation, fever, diaphoresis, coarse tremor hrs

9 Management of Uncomplicated AWS Supportive Care Wernicke s Prophylaxis Risk: thiamine 200mg IV/IM daily Pharmacologic management Benzodiazepines Antiepileptic drugs (AEDs) Ethanol BZD Administration Strategies Prophylaxis Fixed dose Active Symptoms Symptom Triggered Fixed schedule + PRN Front loading

10 Rating Scales in AWS CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol Revised) AWS (Alcohol Withdrawal Symptoms rating scale) SAWS (Short Alcohol Withdrawal Scale) SAS (Severity Assessment Scale)

11 CIWA-Ar CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol Revised) Used to guide AWS management strategies Relatively easy to use Reliable and validated assessment tool for non-medically/surgically ill Scores correlate with severity of AWS - for non-medically/surgically ill NOT diagnostic ---- it is an ASSESSMENT TOOL Inter-rater reliability only fair to poor CIWA-Ar Nausea and Vomiting Tremor Paroxysmal Sweats Anxiety Agitation Tactile Disturbances Auditory Hallucinations Visual Disturbances Headache, fullness in head Orientation, clouding of sensorium

12 CIWA-Ar Considerations Current severity of alcohol withdrawal History of repeated episodes of complicated alcohol withdrawal Level of medical co-morbidity Mental status Patient Location Back up protocol should be available

13 CIWA-Ar Example

14 Fixed-Dose

15 Opiate Withdrawal

16 Opiate Withdrawal Symptoms Stage Clinical Symptoms Onset Early Mid-Late Late Protracted Craving; anxiety; irritability; dysphoria; diaphoresis Insomnia; restlessness; lacrimation; rhinorrhea; diaphoresis; mydriasis; yawning Vomiting, diarrhea, chills, muscle spasms, tremor, tachycardia, piloerection Sleep disturbance, drug craving anhedonia, emotional lability, altered sexual function 4 to 12 hours 8 to 24 hours Up to 3 days Up to 6 months

17 Opiate Withdrawal Scales Clinical Institute of Narcotic Assessment (CINA) 11-items Score: 1-6= Mild; 7-10 Moderate; 11 Severe Clinical Opioid Withdrawal Scale (COWS) 11 items Score: 5 12=Mild; 13 24=Moderate; 25 36=Moderately severe; >36=Severe withdrawal

18 Opiate Withdrawal Management Agonists Methadone (typically 30-40mg in first 24hrs) Buprenorphine (typically 8-16mg first 24hrs) α-2 adrenergic receptor agonist Clonidine ( mg every 2-4 hours) Symptom specific meds Muscle relaxants, NSAIDs, anti-diarrheals, antiemetics, anti-spasmodics (dicyclomine), anxiolytics

19 Opiate Withdrawal Management

20 Opiate Agonists Methadone Peak effect 2-4 hours; t1/ hours Give 10mg increments based on symptoms or give single dose of 20 40mg Not to exceed 40mg in first 24 hours Sample protocol: taper every 24hours 40mg 30mg 20mg 10mg 5mg discontinue Buprenorphine Peak effect 2-4 hours; t1/2 4-6 hours No opioid use for hours with mild-moderate withdrawal with objective signs prior to initiation First dose should not exceed 4mg Sample protocol: taper every 24 hours 8mg 6mg 4mg 2mg d/c Can give in divided doses (ex. 4mg SL bid)

21 Opiate Agonists Efficacy of symptoms resolution is equivalent Buprenorphine: Patients with QTc prolongation Younger patients and/or with less severe opiate use disorder Seems to be associated with faster resolution of symptoms with buprenorphine Seems to be associated with lower risk for adverse outcomes Methadone may be better option: Patients requiring opiate medications Patients who may need operative interventions in next 7 days Patients already on methadone maintenance