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Alcohol Withdrawal Managment

Benzodiazepine as substitution therapy

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
CIWA scores

Alcohol Withdrawal Managment - Seizure Medications

Seizure Medications

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.

Alcohol Withdrawal Managment - Anti Psychotics

Anti Psychotic Medications

Help with sleep, hallucinations, vivid dreams.

Risk of QT prolongation
Monitor QTc by EKG
Correct electrolytes

Quetiapine (Seroquel) 25 - 200 mg q HS

Haloperidol (Haldol)
2-5 mg po
2 mg IM
0.5-1 mg IV

Alcohol Withdrawal Managment - BP meds

BP meds

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
Dexmedetomidine (Precedex)

Alcohol Withdrawal Managment - Thiamine


Deficiency leads to permanent brain damage

Wernicke's enecephalopathy
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 Withdrawal Managment - Why withdraw at all?

Preventing alcohol withdrawal

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
IV ethanol
aggressive benzodizepine dosing

A Protocol for the Prevention Alcohol Withdrawal
Start 5 mg diazepam every 6 h by intravenous or enteral route. Initial dose preoperatively whenever possible.
3diazepam 10 mg. Change to alcohol withdrawal order set.
2diazepam 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
1diazepam 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, -1Do not adjust. Continue scheduled doses
-2, -3diazepam 10 mg. Hold medication and assess RASS score every 1 h until -1 or higher, then resume medication at 50% of prior dose
-4, -5Stop medication and notify MD immediately
The diazepam can be discontinued at time of discharge when patient will be expected to return to active drinking.

Alcohol Withdrawal Managment - RASS?

Richmond Agitation Sedation Scale (RASS)

+4Combative Overtly combative, violent, immediate danger to staff
+3Very agitated Pulls or removes tube(s) or catheter(s); aggressive
+2Agitated Frequent non-purposeful movement, fights ventilator
+1Restless Anxious but movements not aggressive or vigorous
0Alert and calm
-1Drowsy Not fully alert, but has sustained awakening (eye opening/eye contact) to voice (>10 seconds)
-2Light sedation Briefly awakens with eye contact to voice (<10 seconds)
-3Moderate sedation Movement or eye opening to voice (but no eye contact)
-4Deep sedation No response to voice,but movement or eye opening to physical stimulation
-5Unarousable No response to voice or physical stimulatio

Benzodiazepine Dependence

Benzodiazepine Withdrawal

Why withdraw?

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.

Seizure Medication
As with alcohol, valproate and carbamazepine have been proven to reduce withdrawal symptoms.
Not proven to prevent seizures but ARS experience suggests they do.

Anti Psychotic
Helps with sleep and hallucinations. May prevent delirium

Opiate Dependence

Opiate Withdrawal

Why withdraw?

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.

Opiate Dependence - Destination

To know how to go, you have to know where you are going.

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.

Opiate Dependence - Methadone Maintenance

Methadone Maintenance

Opiate Dependence - Methadone Pharmacokinetics

Methadone Pharmacokinetics

Opiate Dependence - Buprenorphine Maintenance

Buprenorphine Maintenance

Opiate Dependence - Buprenorphine Start

Starting Buprenorphine

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

Used sublingually.
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...

Opiate Dependence - Buprenorphine Maintenance Barriers

Buprenorphine Maintenance

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

Opiate Dependence - Buprenorphine Maintenance Forms

Buprenorphine Maintenance

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.

Opiate Dependence - Opiate Antagonist Treatment

Opiate Antagonist

Opiate Dependence - Opiate Withdrawal Medications

Opiate Withdrawal Medications

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
less hypotension?
more effective?

Dexmedetomidine (Precedex)

Opiate Dependence - Opiate Withdrawal Medications

Opiate Withdrawal Medications

Hydroxyzine (Vistaril)
anxiety sedation
25 - 100 mg q 4

Gabapentin (Neurontin)
300 - 800 mg q 8

Loperamide (Imodium)
for diarrhea
opiate in the gut only
2 mg q3 prn

Dicyclomine Bentyl
for stomach cramps
10-20 mg q 4 prn

Opiate Dependence - Opiate Withdrawal Medications

Opiate Withdrawal Medications

Muscle relaxers?
a mixed bag of medications with a variety of mechanisms

Tizanidine (Zanaflex)
central acting alpha-2 agonist
4-8 mg q 6

Cyclobenzaprine (Flexeril)
mechanism similar to tricyclic antidepressant
10 mg q8

Methocarbamol (Robaxin)
also probably tricyclic mechanism
too ataxic when used with tizanidine?

Avoid GABAergic Sedatives
Carisoprodol (Soma)
z drugs: zolpidem (Ambien), Eszopiclone (Lunesta), Zaleplon (Sonata)

Opiate Dependence - Opiate Withdrawal Medications

Opiate Withdrawal Medications

Medications to help with sleep

trazodone 100 mg HS
Quetiapine (Seroquel) 25-150 mg HS

Opiate Dependence - Opiate Withdrawal Medications

Opiate Withdrawal Medications

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

Opiate Dependence - Acute Pain Management for the active Heroin user

Acute Pain Management for the active Heroin user

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.

Opiate Dependence - Acute Pain Management for the active Heroin user

Acute Pain Management for the active Heroin user

Opiate Dependence - Acute Pain Management for the active Heroin user

Acute Pain Management for the active Heroin user

Opiate Dependence - Acute Pain Management for Methadone Maintenance Patients

Acute Pain Management for Methadone Maintenance Patients

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.


Avoid benzodiazepines due to risk of respiratory suppression.

Opiate Dependence - Acute Pain Management for Buprenorphine Maintenance Patients

Acute Pain Management for Buprenorphine Maintenance Patients

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)
0.6 - 1.8 q 8 min
no maximum
nurse boluse 1-2 mg.

hydromorphone (Dilaudid) PO 4-12 mg q 3 hours

Difficult choice
(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.

Opiate Dependence - Acute Pain Management for Opiate Dependent Patients

Acute Pain Management for Opiate Dependent Patients

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.

Opiate Dependence - Discharge Planning

Discharge Planning for Opiate Dependent Patients

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