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

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