Transcript Diagnostic and statistical manual of mental disorders

Alcohol Withdrawal
Anthony Worsham, MD
Thursday School
Division of Hospital Medicine
Department of Internal Medicine
University of New Mexico Health Sciences Center
Thursday, August 7, 2014
The dose makes the poison
What is it that is not a poison? All
things are poison and nothing is
without poison. Solely, the dose
determines that a thing is not a
poison.
--Paracelsus (1493–1541), the
Renaissance Father of Toxicology,
in his Third Defense
Erickson TB, The approach to the patient with an unknown overdose,
Emerg Med Clin N Am 25 (2007) 249–281
http://en.wikipedia.org/wiki/Paracelsus
What is alcohol?
An alcoholic beverage is a drink that typically
contains 3% – 40% alcohol (ethanol)
• beer
• wine
• spirits (distilled beverages)
http://en.wikipedia.org/wiki/Alcoholic_beverage
Alcohol BAC and effects
Kelly JF, Renner JA, Alcohol-Related Disorders, Massachusetts General Hospital Comprehensive
Clinical Psychiatry
http://www.cdc.gov/al
cohol/pdfs/excessive_
alcohol_cost.pdf
What is excessive EtOH use?
49% Prescription opioids(i.e.,methadone,oxycodone,morphine)
36% heroin
31% cocaine
29% tranquilizers/musclerelaxants
16% antidepressants
median age of unintentional drug overdose: 43.7years
O’Connor PG, Alcohol Abuse And
Dependence, Goldman L, Ausiello D, eds.
Cecil Medicine. 23rd ed. Philadelphia, Pa:
Saunders Elsevier; 2007:chap 31.
CAGE questionnaire
1.Have you ever felt you needed to Cut down on your drinking?
2.Have people Annoyed you by criticizing your drinking?
3.Have you ever felt Guilty about drinking?
4.Have you ever felt you needed a drink first thing in the
morning (Eye-opener) to steady your nerves or to get rid of a
hangover?
CAGE test scores >=2 is positive
Excessive drinking: specificity 76%, sensitivity of 93%
alcoholism: specificity of 77%, sensitivity of 91%
Kitchens JM (1994). "Does this patient have an alcohol problem?". JAMA 272 (22):1782–7.
Apply DSM-IV Diagnostic Criteria
for Alcohol Withdrawal
ICD-10 alcohol withdrawal codes
F10.23 Alcohol dependence with withdrawal
F10.230 …… uncomplicated
F10.231 …… delirium
F10.232 …… with perceptual disturbance
F10.239 …… unspecified
Abuse versus dependence: DSM IV-TR
Alcohol abuse
Alcohol dependence
A. A maladaptive pattern of drinking, leading
to clinically significant impairment or distress,
as manifested by at least one of the following
occurring within a 12-month period:
A. A maladaptive pattern of drinking, leading to clinically
significant impairment or distress, as manifested by three
or more of the following occurring at any time in the
same 12-month period:
•Recurrent use of alcohol resulting in a failure to
fulfill major role obligations at work, school, or
home (e.g., repeated absences or poor work
performance related to alcohol use; alcoholrelated absences, suspensions, or expulsions
from school; neglect of children or household)
•Recurrent alcohol use in situations in which it is
physically hazardous (e.g., driving an automobile
or operating a machine when impaired by
alcohol use)
•Recurrent alcohol-related legal problems (e.g.,
arrests for alcohol-related disorderly conduct)
•Continued alcohol use despite having persistent
or recurrent social or interpersonal problems
caused or exacerbated by the effects of alcohol
(e.g., arguments with spouse about
consequences of intoxication).
•Need for markedly increased amounts of alcohol to achieve
intoxication or desired effect; or markedly diminished effect with
continued use of the same amount of alcohol
•The characteristic withdrawal syndrome for alcohol; or drinking
(or using a closely related substance) to relieve or avoid
withdrawal symptoms
•Drinking in larger amounts or over a longer period than intended.
•Persistent desire or one or more unsuccessful efforts to cut
down or control drinking
•Important social, occupational, or recreational activities given up
or reduced because of drinking
•A great deal of time spent in activities necessary to obtain, to
use, or to recover from the effects of drinking
•Continued drinking despite knowledge of having a persistent or
recurrent physical or psychological problem that is likely to be
caused or exacerbated by drinking.
B. No duration criterion separately specified, but several
dependence criteria must occur repeatedly as specified
by duration qualifiers associated with criteria (e.g.,
“persistent,” “continued”).
B. Never met criteria for alcohol dependence.
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.).
Substance use disorder
Diagnostic criteria
A. A problematic pattern of __ use leading to
clinically significant impairment or distress, as
manifested by at least two or the following,
occuring within a 12-month period:
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.).
Substance-use disorders
Diagnostic criteria
• Criteria A
– Impaired control (Criteria 1-4)
– Social impairment (Criteria 5-7)
– Risky use (Criteria 8-9)
– Pharmacological criteria (Criteria 10-11)
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.).
Substance use disorder
Diagnostic criteria: Impaired control
1. __ is often taken in larger amounts or over a
longer period than was intended.
2. There is a persistent desire or unsuccessful
efforts to cut down or control __ use.
3. A great deal of time in spent in activities
necessary to obtain __, use __, or recover from
its effects.
4. Craving, or a strong desire or urge to use __.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.).
Substance use disorder
Diagnostic criteria: Social impairment
5. Recurrent __ use resulting in a failure to fulfill
major role obligations at work, school, or home
6. Continued __ use despite having persistent or
recurrent social or interpersonal problems
caused or exacerbated by the effects of __.
7. Important social, occupational, or recreational
activities are given up or reduced because of __
use.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.).
Substance use disorder
Diagnostic criteria: Risky use
8. Recurrent __ use in situations in which it is
physically hazardous.
9. Alcohol use is continued despite knowledge
of having a persistent or recurrent physical or
psychological problem that is likely to have
been caused or exacerbated by __.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.).
Substance use disorder
Diagnostic criteria: Pharmacology
10. Tolerance, as defined by either of the following:
– a. A need for markedly increased amounts of __ to achieve
intoxication or desired effect.
– b. A markedly diminished effect with continued use of the
same amount of __.
11. Withdrawal, as manifested by either of the
following:
– a. The characteristic withdrawal syndrome for __
– b. __ (or a closely related substance) is taken to relieve or
avoid withdrawal symptoms.
Substance use disorders
Diagnostic criteria
• Specifiers
– In early remission: no criteria met at least 3 months but
less than 12 months
– In sustained remission: no criteria met for 12 months or
longer
– In a controlled environment
– Severity
• Mild: presence of 2-3 symptoms
• Moderate: presence of 4-5 symptoms
• Severe: presence of 6 or more symptoms
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.).
What is alcohol withdrawal?
Camí J, Farré M, Drug Addiction, N Engl J Med, 2003;349:975-86.
Mechanism of action of alcohol
http://thebrain.mcgill.ca/flash/i/i_03/i_03_m/i_03_m_par/i_03_m_par_alcool.html
Alcohol
Intoxication
Withdrawal (2+ within hrs-days)
B. Inappropriate sexual or aggressive
behavior, mood lability, impaired
judgment
•Autonomic hyperactivity
C. 1 or more of:
•Insomnia
•Slurred speech
•Incoordination
•E.g., sweating or pulse rate >100 bpm
•Increased hand tremor
•Nausea or vomiting
•Unsteady gait
•Transient visual, tactile, or auditory
hallucinations or illusions
•Nystagmus
•Psychomotor agitation
•Impairment in attention or memory
•Anxiety
•Stupor or coma
•Generalized tonic-clonic seizures
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.).
Alcohol withdrawal syndrome
progression
Haber P et al.
Guidelines for the
Treatment of Alcohol
Problems. Australian
Government
Department of
Health and Ageing.
2009.
Signs and symptoms of alcohol
withdrawal
Haber P et al. Guidelines for the Treatment of Alcohol Problems. Australian Government Department
of Health and Ageing. 2009.
Alcohol withdrawal spectrum
Alcohol Abuse And Dependence: Patrick G. O’Connor.
UpToDate
Clinical Institute Withdrawal Assessment of
Alcohol Scale, Revised (CIWA-Ar)
• nausea/vomiting
• anxiety
• paroxysmal sweats
• tactile disturbances
• visual disturbances
• tremors
• agitation
• orientation and clouding of sensorium
• auditory disturbances
• headache
Alcohol withdrawal syndrome
admission management goals
1. Monitor course of syndrome, ensuring patient safety
2. Use methods to abort progression and treat
symptoms
3. Manage comorbid medical, surgical, toxicologic, and
psychiatric problems
4. Anticipate need for intensive care monitoring and
therapy
5. Ensure multidisciplinary approach to management,
including preparation for rehabilitation
Carlson RW et al, Alcohol Withdrawal Syndrome, Crit Care Clin 28 (2012) 549–585
Admission studies for patients with moderate to
severe alcohol withdrawal syndrome
1. Complete blood cell count
2. Baseline metabolic panel with serum electrolytes (including magnesium), glucose,
renal function tests
3. Blood alcohol, and urine and blood toxicology studies
4. Serum calcium, phosphate, lipase, CPK activity
5. Liver function tests, including INR and serum AST, ALT, bilirubin, ammonia
6. Chest radiograph
7. Electrocardiogram, cardiac biomarkers, echocardiogram
8. Urinalysis
9. Arterial blood gas analysis
10. Blood, urine, and sputum cultures
Abbreviations: ALT, alanine aminotransferase; AST, aspartate aminotransferase; CPK, creatine
phosphokinase; INR, international normalized ratio.
Laboratory, imaging, and clinical evaluations must be individualized.
Carlson RW et al, Alcohol Withdrawal Syndrome, Crit Care Clin 28 (2012) 549–585
Moeller KE, Urine Drug Screening:
Practical Guide for Clinicians, Mayo
Clin Proc. 2008;83(1)66-76
Alcohol labs
Blood alcohol level
Alcohol-use disorders
Marc A Schuckit, Lancet 2009; 373: 492–501
Osmolar Gap
Levine M et al, Toxicology in the ICU: Part 1: General Overview and Approach to Treatment. Chest
2011; 140( 3 ): 795 – 806
MKSAP question
A 39-year-old man is admitted to the hospital
for new-onset agitation, fluctuating level of
consciousness, and tremors. He is diagnosed
with acute alcoholic hepatitis.
MKSAP Question
On physical examination, temperature is 38.8°C (101.8°F), blood
pressure is 95/55 mm Hg, pulse rate is 130/min, and
respiration rate is 30/min. Jaundice is noted. The abdomen is
protuberant with ascites but is soft, with no abdominal
rigidity or guarding. There is no blood in the stool. The patient
is agitated and disoriented, is unable to maintain attention,
and appears to be having visual hallucinations. He believes
that the nurse has stolen his wallet (which is in his bedside
drawer) in order to obtain his identity. He is diaphoretic and
tremulous. Asterixis is absent, and the remainder of the
neurologic examination is normal.
MKSAP Question
Q: Which of the following is the most
appropriate management?
A. Ceftriaxone
B. CT of the head
C. Haloperidol
D. Lactulose enema
E. Lorazepam
What is delirium tremens?
What is delirium tremens?
Delirium
Diagnostic Criteria
A.
A disturbance in attention (i.e., reduced ability to direct, focus, sustain, and shift
attention) and awareness (reduced orientation to the environment).
B.
The disturbance develops over a short period of time (usually hours to a few
days), represents a change from baseline attention and awareness, and tends to
fluctuate in severity during the course of a day.
C.
An additional disturbance in cognition (e.g., memory deficit, disorientation,
language, visuospatial ability, or perception).
D.
The disturbances in Criteria A or C are not better explained by another
preexisting, established, or evolving neurocognitive disorder and do not occur
in the context of a severely reduced level of arousal, such as coma.
E.
There is evidence from the history, physical examination, or laboratory findings
that the disturbance is a direct physiological consequence of another medical
condition, substance intoxication or withdrawal (i.e., due to a drug of abuse or
to a medication), or exposure to a toxin, or is due to multiple etiologies.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.).
Differentiate delirium tremens from
other alcohol withdrawal syndromes
• 5% of patients with alcohol withdrawal
• Constellation of symptoms: confusion, hallucinations, fever
(with or without evidence of infection), and autonomic
hyperresponsiveness with hypertension and profound
tachycardia
• Suspect in any agitated patient withdrawing from alcohol
with BP >140/90 mm Hg, HR > 100/min, T > 101 Fahrenheit
• Mortality 5-15%
Erwin WE et al, Delirium tremens, Southern Medical Journal (May 1998, 91:5), 425-432.
MKSAP Question
Correct answer: E. Lorazepam.
The most appropriate treatment is lorazepam for delirium tremens
syndrome. The term delirium tremens is nearly universally used to refer to
delirium due to alcohol withdrawal syndrome. The syndrome usually
presents 48 to 96 hours after cessation of drinking, can last up to 2 weeks,
and is usually exacerbated at night. The syndrome is characterized by
impaired level of consciousness and disorientation (which may fluctuate
significantly), reduced attention and global amnesia, impaired cognition
and speech, and often hallucinations (usually tactile and/or visual) and
delusions (persecutory). The condition can be rapidly fatal if not treated
appropriately and aggressively. Seizure activity can occur.
Benzodiazepines are the treatment of choice, with doses given as needed
based on exhibited signs and symptoms consistent with alcohol
withdrawal.
Delirium tremens
Key Points
Delirium tremens is characterized by fluctuating
level of consciousness, disorientation,
reduced attention, global amnesia, impaired
cognition and speech, and often
hallucinations and delusions.
Risk factors for severe course of AWS,
including seizures and delirium
1. Prior episodes of AWS requiring detoxification, including seizures or delirium (kindling)
2. Grade 2 severity or higher on presentation (CIWA-Ar Score >10)
3. Advanced age
4. Acute or chronic comorbid conditions, including alcoholic liver disease, co-intoxications,
trauma, infections, sepsis
5. Detectable blood alcohol level on admission
6. Use of “eye opener,” high daily intake of alcohol, or number of drinking days/month
7. Abnormal liver function (serum aspartate aminotransferase activity >80 U/L)
8. Prior benzodiazepine use
9. Male sex
Abbreviation: CIWA-Ar, Clinical Institute of Withdrawal Assessment for Alcohol, revised.
Carlson RW et al, Alcohol Withdrawal Syndrome, Crit Care Clin 28 (2012) 549–585
Potential indications for ICU
management
1. Advanced Stage 2 or greater alcohol withdrawal syndrome
2. Critical comorbid conditions including: trauma; severe sepsis; respiratory
failure; acute respiratory distress syndrome; hemodynamic instability;
gastrointestinal bleeding; hepatic failure; pancreatitis; rhabdomyolysis;
co-intoxication; coagulopathies; acute CNS process; cardiac arrhythmias,
ischemia, or congestive failure; severe fluid or electrolyte defects; renal
failure; persistent fever; or complex acid-base defects
3. Escalating intravenous bolus or continuous-infusion sedation therapy
4. Persistent fever >39 C
Carlson RW et al, Alcohol Withdrawal Syndrome, Crit Care Clin 28 (2012) 549–585
Alcohol treatment medications
O’Connor PG, Alcohol Abuse And Dependence, Goldman L, Ausiello D, eds. Cecil Medicine. 23rd
ed. Philadelphia, Pa: Saunders Elsevier; 2007:chap 31.
Criteria for different withdrawal
settings
Haber P et al. Guidelines for the Treatment of Alcohol Problems. Australian Government Department of Health
and Ageing. 2009.
Literature review
1 RCT; 3 cohort studies (2 retrospective)
Stephens JR, et al. Who Needs Inpatient Detox? Development and Implementation of a Hospitalist Protocol for the
Evaluation of Patients for Alcohol Detoxification. J Gen Intern Med. Published online 07 January 2014.
Task Force: 3 MD, 1 NP, 1 RN case manager
Clinical questions
Is inpatient or outpatient treatment superior for alcohol
detoxification?
What factors should guide decisions on inpatient versus
outpatient treatment?
Literature search
PubMed (years 1980 to 2011) utilizing combinations of
the search terms “alcohol detoxification,” “inpatient,”
“outpatient,” and “ambulatory”
review of reference sources
Stephens JR, et al. Who Needs Inpatient Detox? Development and Implementation of a Hospitalist Protocol for the
Evaluation of Patients for Alcohol Detoxification. J Gen Intern Med. Published online 07 January 2014.
Stephens JR, et al. Who Needs Inpatient Detox? Development and
Implementation of a Hospitalist Protocol for the Evaluation of Patients
for Alcohol Detoxification. J Gen Intern Med. Published online 07 January
2014.
Asplund CA et al. Regimens for alcohol
withdrawal and detoxification. J Fam Pract
53:7. (2004)
Stephens JR, et al. Who Needs Inpatient Detox? Development and Implementation of a Hospitalist Protocol for the
Evaluation of Patients for Alcohol Detoxification. J Gen Intern Med. Published online 07 January 2014.
Results
Alcohol detoxification admissions: 15.9 v.
18.9/month, p=0.037
Average LOS: 3.4 versus 2.7 days, p=0.09
26.5
Readmission rate: 28.4% v. 26.5%; p=0.33
7-day repeat ED visit: 10.8% v. 8.8%
AMA discharges: 18 (1.0/month) v. 16 (2.7/month)
Protocol adherence: 15/18 cases (83.3%)
Cost savings: $8742 /case, $315,000/yr
Stephens JR, et al. Who Needs Inpatient Detox? Development and Implementation of a Hospitalist Protocol for the
Evaluation of Patients for Alcohol Detoxification. J Gen Intern Med. Published online 07 January 2014.
Weaknesses
Unable to definitively tell if protocol is sole
reason for decreasing alcohol withdrawal
admissions
Cannot determine safety because patients not
admitted not followed
Stephens JR, et al. Who Needs Inpatient Detox? Development and Implementation of a Hospitalist Protocol for the
Evaluation of Patients for Alcohol Detoxification. J Gen Intern Med. Published online 07 January 2014.
Metropolitan Assessment And
Treatment Services (MATS)
http://www.bernco.gov/news/139305/
http://www.bernco.gov/mats-faq/
Metropolitan Assessment And
Treatment Services (MATS)
Qualifications
◦Bernalillo County resident or homeless.
◦18 years of age or older.
◦ In need of detoxification from alcohol or dual substances. If methadone and more
than 30 mgs, the person cannot be admitted. If heroin, alcohol, cocaine, etc., not
used within the last three days, cannot admit unless symptoms are presenting.
◦If the person is on any life-sustaining prescription medications (such as insulin for
diabetes), must have the prescription medication with them. (Note: If the person
is on psychiatric drugs but does not have the medication with them, the person
can be admitted if not presenting and seems stable.).
◦ Must not have any restraining orders or warrants for arrest.
◦Must not have any appointments within the next 24 hours and up to the next 3 - 5
days. Admission to these services would most likely prevent the person from
making that appointment.
◦Individuals must be mobile or able to move without assistance from others.
http://www.bernco.gov/mats-faq/
http://www.bernco.gov/news/139305/
UNM Alcohol Withdrawal Powerplan
UNM Alcohol Withdrawal Powerplan
Arch Intern Med. 2002 May 27;162(10):1117-21. Symptom-triggered vs fixed-schedule doses of benzodiazepine for alcohol
withdrawal: a randomized treatment trial. Daeppen JB1, Gache P, Landry U, Sekera E, Schweizer V, Gloor S, Yersin B.
prospective, randomized, double-blind, placebo
controlled
P: adult ED pts admitted to Alameda Co. Medical
Center/Highland Hospital, CA w/ alcohol withdrawal
I: phenobarbital 10 mg/kg in 100 mL NS + “CIWA”
C: 100 mL NS + “CIWA”
O: primary: initial level of hospitalization
other: lorazepam gtt, LOS, lorazepam total dose,
adverse events
Rosenson J, Clements C, Simon B, et al. Phenobarbital for acute alcohol withdrawal: a prospective randomized doubleblind placebo-controlled study. J Emerg Med. 2013;44(3):592-598.e2. doi:10.1016/j.jemermed.2012.07.056.
UNM CIWA protocol
Strategies for Cutting Down
from Helping Patients Who Drink Too Much: A Clinician’s Guide. 2005.