1
What are the symptoms of alcohol withdrawal?
Mild: Anxiety, tremors, insomnia, nausea, vomiting
Severe: Delirium Tremens
When would people with alcohol dependence require
assistance with withdrawal and where can they be
treated?
People with mild alcohol dependence usually don't
require assisted alcohol withdrawal
Patients with moderate alcohol dependence usually
require assisted alcohol withdrawal and can be
treated in primary care unless they are at risk of
developing alcohol withdrawal seizures and delirium
tremens
individuals with severe dependence should undergo
withdrawal in an inpatient setting. Patients with
decompensated liver disease should be treated under
specialist supervision.
How is alcohol withdrawal treated?
Assisted alcohol withdrawal:
1. Chlordiazepoxide OR diazepam
Alternatives are carbamazepine [unlicensed],
clomethiazole (only used in an inpatient setting. Can
cause fatal respiratory depression when taken with
alcohol)
In primary care a fixed-dose reducing regimen
In an inpatient or residential setting a fixed dose or
symptom-trigged regimen
Alcohol withdrawal seizures:
Lorazepam (fast acting benzodiazepine) [unlicensed]
Delirium tremens:
1. Oral lorazepam
Persistent or if patient declines oral treatment:
parenteral lorazepam [unlicensed] or haloperidol
[unlicensed]
What is delirium tremens?
Life threatening alcohol withdrawal syndrome
What are the symptoms of delirium tremens?
agitation, confusion, paranoia, and visual and auditory
hallucinations
can lead to cardiovascular collapse
How is alcohol dependence treated?
CBT +
Acamprosate or naltrexone (after successful alcohol
withdrawal)
Alternative: disulfiram
What are the cautions of taking disulfiram?
Small amounts of alcohol can cause a very unpleasant
systemic reaction with symptoms such as flushing,
throbbing headache, palpitations, tachycardia,
nausea, vomiting
What drug is used to aid patients reduce alcohol
consumption if they don't have physical withdrawal
symptoms and do not require immediate
detoxification?
Nalmefene: For patients with a high drinking risk level,
who do not require immediate detoxification
What are alcoholics at risk of?
Wernickes encephalopathy due to malnourishment of
decompensated liver disease
How is wernicke's encephalopathy prevented?
IV Thiamine then PO thiamine (vitamin B1)
How is nicotine dependence treated?
Nicotine replacement therapy
Bupropion
Varenicline
Can NRT and bupropion and varenicline be used
together?
It is not recommended
What are the types of NRT?
Prolonged release formulations: 16/24 hour patch
immediate release formulations: urge to
smoke/prevent craving
> Gum, lozenge, nasal spray, oral spray, sublingual
tablet, inhalator
When is a 24 hour patch recommended?
Use 24 hour patch if strong cravings for cigarettes on
waking
What are the side effects of NRT?
Mild local reactions due to irritant effects to nicotine -
skin irritation with patches , throat irritation with
inhalators and oral preperations
Gastrointestinal disturbances: nausea, vomiting,
dyspepsia, hiccup
What is the mechanism of action of varenicline?
Selective nicotine receptor partial agonist
When is varenicline used?
In patients with an expressed desire to stop smoking
in conjunction with behavioural therapy
When should varenicline be discontinued?
Stop and see GP if experiencing agitation, depression,
suicidal thoughts
How is opioid dependence treated?
 2

Opioid substitution with methadone or What are the benefits of taking buprenorphine over
buprenorphine, naltrexone methadone?
In comparison to methadone:
What is the mechanism of action of methadone? Less sedating so best if a patient has a job or drives
It is a full opioid agonist Safer when used with other sedating drugs
Fewer drug interactions
How is methadone dosed? Milder withdrawal reaction
Once daily Lower risk of overdose

When is methadone initiated? What is insomnia?

At least 8 hours after the last heroine dose when
there is objective evidence of withdrawal symptoms
What are the side effects of methadone?
QT interval prolongation
increased risk of toxicity in non-dependent patients
Has a long half life so can accumulate and cause
toxicity (dose tolerated on day 1 may cause toxicity on
day 3) - titration to optimal dose may take several
weeks
Sedating
When is methadone preferred over buprenorphine?
Long history of opioid misuse
Increased anxiety during withdrawal
If they abuse sedative drugs/acohol
How many missed doses does it take to lose tolerance
to methadone?
3 or more.
Risk of overdose if taken after 3 missed doses
After how many missed doses should a HCP check if a
methadone patient is abusing opioids?
5 or more missed days
*especially important in patients taking
buprenorphine because it can precipitate withdrawal
reactions
What is the mechanism of action of buprenorphine?
Partial mu opioid agonist
Difficulty in falling asleep or staying asleep
What are the symptoms of insomnia?
Difficulty initiating sleep
Difficulty maintain sleep
Early morning awaking
Poor sleep quality
What are the types of insomnia?
Transient
Short term
Chronic
What are the causes of transient insomnia?
Environmental factors such as noise, shift work, jet leg
How is transient insomnia treated?
If needed short -acting drugs (so they are rapidly
eliminated)
Give only 1 or 2 doses
What are the causes of short term insomnia?
Related to emotional problem or a serious medical
illness
May last a few weeks and may recur
How is short term insomnia treated?
Hypnotics can be taken intermittently with some
doses omitted
Short acting hypnotic preferred
Give for no more than 3 weeks

What is the frequency of dosing of buprenorphine? What are the causes of chronic insomnia?
Once daily Psychiatric disorders e.g. anxiety and depression,
Can be given on alternate days in higher doses alcohol and drug abuse
Pain
What are the side effects of buprenorphine? Dyspnoea
Can precipitate withdrawal reactions Pruritus

When should buprenorphine be taken? How is chronic insomnia treated?

Take first dose when withdrawal signs occur Treating the underlying cause
Take first dose 6-12 hours after heroin
24-48 hours after methadone

Which drugs are used for insomnia?
Benzodiazepines
Z-drugs
antihistamines (promethazine, diphenhydramine) melatonin
receptor agonists (pineal hormone in over 55 years)
antidepressants
clomethiazole (Use: elderly; no hangover effect. Also licensed
for acute alcohol withdrawal)
chloral hydrate (use as hypnotic is very limited)
Which drugs, previously used for insomnia, are no longer
recommended and why?
Meprobamate and barbiturates
They have more side effects, interactions and are more
dangerous in overdose
What is the indication for Z-drugs?
Short term use (4 weeks max; 2 weeks if zaleplon) for severe
insomnia that interferes with daily life
What is the mechanism of action of Z-drugs?
Act on benzodiazepine site of GABAa receptors to facilitate
and enhance binding of GABA to GABAa receptors
Are Z-drugs short acting or long acting?
Short acting
Give examples of Z-drugs
Zolpidem (taste disturbance)
Zopiclone (GI disturbances, leave 8 hours before driving)
Zaleplon (shortest acting)
What are the side effects of Z-drugs?
Paradoxical effects: paradoxical increase in hostility and
aggression: talkativeness and excitement to aggression and
antisocial acts. Also increased anxiety and perceptual
disorders. Dose adjustments (up or down) can sometimes
attenuate the impulses
Daytime sleepiness. Avoid alcohol; CNS depression enhanced
Avoid long-term use:
Can lead to dependence and withdrawal reactions, rebound
insomnia, broken sleep with vivid dreams. -> Avoid abrupt
withdrawal
Tolerance develops in 3 to 14 days of continuous use: Take
only when needed
What is the indication for benzodiazepines?
Short term use (2-4 weeks) for severe, disabling insomnia or
causing patient extreme stress
Which benzodiazepines are long acting?
Nitrazepam
Flurazepam
Diazepam - can provide anxiolytic effects during the day when
taken as a single dose at night
When are long acting benzodiazepines used?
Sleep-maintenance insomnia (early morning waking) that
causes daytime effects
Good for early risers
Where daytime effects of BZDs are acceptable
Where daytime anxiolytic effect is beneficial
Which benzodiazepines are short acting?
3
Temazepam (CD3, Dental procedures-preferred)
Lorazepam (Dental procedures, insomnia associated with
anxiety)
Loprazolam
Lormetazepam
Oxazepam (insomnia associated with anxiety)
When are short acting benzodiazepines used?
Sleep onset insomnia (difficulty getting to sleep)
What are the benefits of short acting hypnotics?
Better for elderly patients
Good for patients where sedation the following day is
undesirable - Have little handover effect, therefore can drive
and have a job
Which drugs are used for conscious sedation of patients prior
to a dental procedure
Temazepam - preferred as shorter acting so won't cause
residual effects the following day
Diazepam
Lorazepam
In what group of patients should benzodiazepines be avoided
and why?
Hepatic impairment; BZDs can precipitate hepatic coma if used
in hepatic impairment
Shorter acting benzodiazepines are safer if they are required!
In what group of patients should Z-drugs/benzodiazepines be
avoided and why?
In elderly as they cause ataxia and confusion which can lead to
falls and injury
Patients with hepatic impairment because it can precipitate a
hepatic coma - can cause drowsiness
How quickly can tolerance to hypnotics develop?
Tolerance develops in 3 to 14 days of continuous use: Take
only when needed
What information should be given to patients tapering off
hypnotics?
Stopping hypnotics after long term use can cause withdrawal
reactions (due to dependence) and rebound insomnia. More
common with short acting hypnotics e.g. zaleplon
When stopping after long term use sleep can be disturbed
before a normal sleep pattern is reestablished. However
broken sleep with vivid dreams can persist for weeks
What are the symptoms of narcolepsy?
Sleep attacks
Excessive daytime sleepiness
Cataplexy (temporary loss of muscle control)
Sleep paralysis
Excessive dreaming
What are the treatments for narcolepsy?
CNS stimulants
> Modafinil (CD2)
> Methylphenidate (CD2)
> Dexamfetamine (CD2)
> Sodium oxybate (CD2)
> Pitolisant