Oversight

... or, "How I learned to stop worrying and love being second-guessed." Getting used to it: Anger and Resentment Need for quick, efficient communication of case Need for clinical justification of treatment decisions The problem of "How do we know when we're done?"
Alexander DeLuca, M.D., FASAM

Tenets of Detoxification
Prevent medical complications Prevent psychiatric complications Humane and dignified withdrawal

Assess / Engage / Motivate / Refer

Alexander DeLuca, M.D., FASAM

Approach to the patient

Chronic, relapsing, progressive disease that can be treated Non-judgmental; permission-giving; empathic Demonstrate understanding and gain trust by sensitively investigating medical, psychological and social consequences of addiction
Alexander DeLuca, M.D., FASAM

Terms
Tolerance

Withdrawal
Dependence Addiction

Neuroadaption
Kindling
Alexander DeLuca, M.D., FASAM

High Risk of Complicated Withdrawal

Medically managed inpatient detox indicated if:
OD in progress: compromised vitals, mental/cardiac decompensation, stupor, delirium Head trauma, Sz, or DTs within past 24 hours History recurrent / multiple Sz Daily sedatives > therapeutic > 4 weeks Daily therapeutic sed. + etoh > 6 weeks CIWA >= 15 or BAC >= 0.3 + AWS CIWA 10-19 + P > 110 or BP > 160/110
Alexander DeLuca, M.D., FASAM

Predictors of Alcohol Withdrawal Severity

Prior Hx of severe withdrawal (kindling) High BAC without signs of intoxication

Signs of AWS accompanied by high BAC

Concurrent use of sedative-hypnotics Coexisting medical problems
Alexander DeLuca, M.D., FASAM

Alcohol Withdrawal Syndrome

Tremor, anxiety, agitation, HTN, tachycardia, diaphoresis, hyperpyrexia, insomnia, hallucination, seizure

Sensorium usually clear Treat AWS to prevent seizures , DT's, and kindling
Alexander DeLuca, M.D., FASAM

Alcohol - related seizures

Gran mal in 10-15% (Guthrie, 1989) Usually in first 48 hours but may be seen up to 10 days May be multiple, rarely status, may require diazepam 10 mg slow IVP 1st episode or atypical seizure: evaluate for other causes Ongoing pharmacotherapy not indicated for w/d seizures
Alexander DeLuca, M.D., FASAM

Delirium Tremens
Acute, reversible, organic psychosis; significant morbidity and mortality Usually begins 36 - 72 hours; may last 2 - 10 days and sometimes longer

Severe AWS symptoms with clouded sensorium

Hallucinations w/o insight produce panic and severe agitation Mortality increases with delayed Dx, inadequate Rx, and concurrent medical conditions.
Alexander DeLuca, M.D., FASAM

Treatment of AWS
Fixed Dose Regimen
Librium 50 / 25 / 10mg PO Q4hr W/A Ativan 2 / 1.5 / 1mg PO Q4hr W/A

Three days meds, one day of observation,

Ativan 1-2 mg PO or IM prn Sx AWS

Ancillary medications
Alexander DeLuca, M.D., FASAM

Treatment of AWS
Symptom-driven Regimen
Use CIWA scale serially
Medicate or observe based on w/d score Pro's: less meds, shorter LOS Con's: requires training, discharge flexibility
Alexander DeLuca, M.D., FASAM

Treatment of Delirium Tremens

Fluid and electrolyte management Pharmacotherapy - hourly Librium 100 mg PO, or valium 10mg IV, till asleep Consider addition of anti-psychotics (after BZDs or may precipitate seizure) Physical restraint may be necessary
Alexander DeLuca, M.D., FASAM