Works at the GABA receptor
...taking the place of alcohol and gently weaning the patient down.
Key questions are "How much?" and "When?"
Symptom based treatment with
Proven to reduce alcohol withdrawal symptoms:
Anxiety, Insomnia, CIWA scores
Not proven to prevent seizures
Phenytoin (Dilantin) shown to not prevent alcohol withdrawal seizures.
Experience at Swedish ARS suggest that Valproate and Carbamazepine do prevent alcohol withdrawal seizures.
Help with sleep, hallucinations, vivid dreams.
Risk of QT prolongation
Monitor QTc by EKG
Quetiapine (Seroquel) 25 - 200 mg q HS
2-5 mg po
2 mg IM
0.5-1 mg IV
Beta blockers and central acting alpha 2 agonists reduce sweat, tremor, anxiety.
Mask symptoms (and reduce CIWA scores) but do not decrease risk of seizures.
Centeral acting alpha 2 agonists
Deficiency leads to permanent brain damage
agitation, ataxia, delirium, nystagmus
only a minority get nystagumus
Presentation very similar to alcohol withdrawal / DTs
most patients diagnosed at time of autopsy were not diagnosed in life
Prevention & Treatment with Thiamine
Typically dosed 100 mg IV or PO daily for prevention
PO absorption is very low
treatment dose is 500 mg IV TID
Given the difficulty of distinguising Wernicke's encephalopathy from alcohol withdrawal delirium,
suggest treatment doses of thiamine for patient's with DTs
Alcohol dependent patients presenting for medical or surgical care and are not expected to stop drinking.
Alcohol withdrawal has significnat risks to the patient and increases length of stay and cost of care.
contine drinking beverage alcohol
aggressive benzodizepine dosing
|3||diazepam 10 mg. Change to alcohol withdrawal order set.|
|2||diazepam 10 mg, reassess in 30 min and dose again if needed. Increase scheduled dose to q 4 hours AND Increase scheduled dose by 5 mg up to max of 20 mg q4h|
|1||diazepam 5 mg decrease dosing interval to q4h, if this has already been done increase scheduled dose by 5 mg to max 20 mg q4h|
|0, -1||Do not adjust. Continue scheduled doses|
|-2, -3||diazepam 10 mg. Hold medication and assess RASS score every 1 h until -1 or higher, then resume medication at 50% of prior dose|
|-4, -5||Stop medication and notify MD immediately|
|+4||Combative Overtly combative, violent, immediate danger to staff|
|+3||Very agitated Pulls or removes tube(s) or catheter(s); aggressive|
|+2||Agitated Frequent non-purposeful movement, fights ventilator|
|+1||Restless Anxious but movements not aggressive or vigorous|
|0||Alert and calm|
|-1||Drowsy Not fully alert, but has sustained awakening (eye opening/eye contact) to voice (>10 seconds)|
|-2||Light sedation Briefly awakens with eye contact to voice (<10 seconds)|
|-3||Moderate sedation Movement or eye opening to voice (but no eye contact)|
|-4||Deep sedation No response to voice,but movement or eye opening to physical stimulation|
|-5||Unarousable No response to voice or physical stimulatio|
If the patient is going to continue to take benzodiazepine post hospitalization, there is no benefit in withdrawing.
For patients on prescribed medication, coordinating with the prescriber is the most useful step.
As with alcohol, valproate and carbamazepine have been proven to reduce withdrawal symptoms.
Not proven to prevent seizures but ARS experience suggests they do.
Helps with sleep and hallucinations. May prevent delirium
Harrison Narcotic Act of 1914
Illegal to prescribe opiates for addiction but not for pain.
Exepmtion for hospital care.
Thus why withdraw?
We hope patient will remain sober.
Avoid recurrent complications of IV drug use.
Patients admitted for med surg problems
while using opiates
are almost always
going to continue opiate use
after hospital discharge.
Why not just stop?
If I could just get over the hump....
Patients think they are using only because of the withdrawal.
But patients who have detoxed successfully, almost always relapse without some ongoing treatment.
As opiate antagonist can cause precipitated opiate withdrawal.
Typically requires 24 hours after last short acting opiate, 3 days after last methadone.
Patients must already be in withdrawal to begin buprenorphine
This is going to be a problem for patients in acute pain
Usual maintenance dose is 8 - 16 mg SL daily.
Comes in 2 and 8 mg doses sublingual tabs and films.
There is a parenteral buprenorphine that can also be absorbed sublingually
We have found that smaller doses (as low as 0.15 mg) can be started sooner...
Costs $300-500 per month depending on dose
Private insurance covers
Medicare Part D covers
DSHS covers but: life time 6 months maximum, must be participating in outpt treatment program, approval takes 1-2 weeks.
Must find a physician who has taken 8 hour course and applied for a waiver to prescribe.
Some of these doctors charge cash for appts.
A list of prescribing doctors can be found online at suboxone.com
buprenorphine with naloxone.
The naloxone is not significantly absorbed sublingually. It's there to prevent misuse by IV injection.
available in tables and films
pure buprenophine tablets
Somewhat higher risk of misuse.
Much cheaper as it is available generically.
Typically used only for pregnant people.
Just plain detox meds
Never adequate to prevent use.
Can be helpful for motivated patient.
Withdrawal symptoms are increaesd by triggers that remind patient of opiate use
for restlessness, heebee geebees, sweats
0.1 mg q 1-4 hours, watch BPs
central acting alpha 2 agonist
Tizanidine (Zanaflex) 4-8 mg q 6 hours
25 - 100 mg q 4
300 - 800 mg q 8
opiate in the gut only
2 mg q3 prn
for stomach cramps
10-20 mg q 4 prn
a mixed bag of medications with a variety of mechanisms
central acting alpha-2 agonist
4-8 mg q 6
mechanism similar to tricyclic antidepressant
10 mg q8
also probably tricyclic mechanism
too ataxic when used with tizanidine?
Avoid GABAergic Sedatives
z drugs: zolpidem (Ambien), Eszopiclone (Lunesta), Zaleplon (Sonata)
Medications to help with sleep
trazodone 100 mg HS
Quetiapine (Seroquel) 25-150 mg HS
Blue Plate Special
Dr. Greg Rudolf
Tizanidine 8 mg po q 6
Hydroxyzine 100 mg po q4 (hold if sleeping)
Gabapentin 300 AM, 300 PM, 600 HS
start with pain meds (opiates) as needed for pain and withdrawal
patient controlled whenever possible
scheduled whenever possible (but watch out overdose)
PRN medications make both the patient and nurse unhappy
it doesn't matter if the med is for pain or withdrawal.
The law allows either.
You can't tell and the patient can't tell either.
The methadone does not relieve any pain.
The maintenance medication is what makes the patient feel normal.
Methadone prevents the euphoria but not pain relief effects of medications
Patients are very tolerant and may need very high doses of pain medication.
IF THE PATIENT IS BREATHING IT ISN'T TOO MUCH.
Avoid benzodiazepines due to risk of respiratory suppression.
As with methadone patients there is no relief of pain from their maintenance medication.
High tolerance as with methadone patients (maybe not quite as much)
More importantly they are blocked at the opiate receptor for both euphoria and pain relief.
Very high doses of very high affinity opiates (hydromorphone, fentanyl) will be needed to relieve pain
PCA: hydromorphone (Dilaudid)
|hydromorphone (Dilaudid) PO 4-12 mg q 3 hours|
(1) stop the buprenorphine, as it is blocking pain relief.
Buprenorphine will wear off over three days.
It will have to be restarted with period of acute withdrawal.
Risk of relapse to illicit drug use
(2) continue the buprenorphine with ongoing high dose pain med requirement.
How long to give pain meds?
the same as other patients.
Active illicit uses will never find it to be long enough,
they will have to return to illicit, expensive use,
you can't trust what they tell you.
Set a deadline and stick to it.
Anticipate they will return to illicit use.
Methadone and Buprenorphine users should come off thier very high doses
in no more days than opiate naive patients do with thier lower doses.
Discharge to Methadone Maintenance?
Can we get a spot at DSHS funded clinic? Can they pay cash?
What if there is a gap of time before they can start methadone maintenance? They use until they get in.
Discharge to Suboxone?
Can they afford (or have insurance)
Poly substance user?
Using friends of family members?
Can they tolerate period of withdrawal?
Not really an option for acute / surgical pain patients
Discharge to Rehab?
Insurance coverage? Financial support from family?
Family may help motivate / pressure patient to go to rehab
Discharge on Naltrexone (Vivitrol
Only viable for fairly long stays and not needing pain medication
Consider transfer to Swedish Ballard ARS
Patients motivated to stop substance use and begin treatment
Private insurance or Medicare