Alcohol and nicotine withdrawal
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Transcript of Alcohol and nicotine withdrawal
Alcohol and nicotine are widely abused substances and are often used together
One study showed that 15% of patients visiting a primary care practice for any reason had either an “at-risk” pattern of alcohol use or an alcohol related health problem
It is important to note that alcohol contributes and leads to a wide range of medical problems and is also a significant contributor to trauma
Alcohol use history is important in all patients
In trauma patients exclude head injury before ascribing unusual behaviour to alcohol withdrawal but conversely keep alcohol withdrawal in mind for all patients with an altered mental status of unknown aetiology
High likelihood in following patients:◦ Alcohol-related reason for admission
◦ Regular use >80g/day in males, >60g/day in females
◦ >30 years of alcohol use
◦ <10 days since last drink
◦ History of alcohol dependence/previous withdrawal
Range from mild withdrawal to severe withdrawal and delirium tremens
Start within 6 to 24 hours of last drink, peak over 36 – 72 hours
Subside over a few days but mood and sleep disturbance may persist for weeks
Seizures can occur early in course –usually of short duration and self-limiting but may progress to status epilepticus
History of previous severe withdrawal
Use of >150mg alcohol per day
Presence of other illness/injury
History of head injury
Use of other psychotropic drugs
Patients at risk for severe withdrawal should be closely monitored and receive early and aggressive treatment ideally in high care setting
Agitation
Restlessness
Gross tremor
Disorientation and mental confusion
Fluctuating level of consciousness
Fluid and electrolyte imbalances
Sweating and pyrexia
Visual hallucinations
Paranoia
Identify and treat underlying medical conditions
Control behaviour
Prevent injuries
High dose benzodiazepines (not > 100mg/hour or 250mg in 8 hours)
Result of thiamine deficiency
Life threatening condition◦ Global confusional state
◦ Ocular disturbances: horizontal nystagmus, opthalmoplegia, CN VI palsy with diplopia
◦ Ataxia
Treatment:◦ Thiamine 300mg IVI for 3-5 days, then 100-300mg
po dly
All withdrawal patients should receive Thiamine 300mg IVI stat on presentation
Benzodiazepines
◦ Treatment of choice
◦ Reduce withdrawal severity and incidence of seizures and delirium
◦ Good safety profile
◦ Usually long-acting but can give short-acting in cases of liver disease
◦ Given for short period of time due to potential for abuse
◦ Dosing: Fixed dose, loading dose followed by fixed dose or symptom triggered therapy
Symptom-triggered therapy requires close monitoring, not ideal except in dedicated detoxification centre
Fixed dose in mild withdrawal◦ Day 1 – 5-15mg qid
◦ Day 2 – 5-10mg qid
◦ Day 3 – 5-10mg tds
◦ Day 4 – 10mg bd
◦ Day 5 – 5mg bd
Loading dose therapy is indicated in cases of a high level of dependency or a patient at high risk for severe withdrawal
Loading dose of 10-20mg diazepam every 2-4 hours until light sedation achieved, then then 10mg 4-6hourly, wean slowly over next 5 days
Anticonvulsants:◦ Phenytoin has no benefit
◦ Valproate and Carbamazepine increase seizure threshold
Thiamine:◦ 300mg IVI stat, then 100mg dly for 7 days
Antipsychotics/sedatives:◦ Phenothiazines/Haloperidol – decrease symptoms
but less effective than benzos – adjunct in severe withdrawal with perceptual disturbances, can decrease seizure threshold
ß-blockers and clonidine – reduce autonomic manifestations, ß-blockers may mask symptoms of early withdrawal or impending delirium
Symptomatic treatment ◦ Metoclopramide for nausea and vomiting
◦ Buscopan for abdominal cramps
◦ Immodium for diarrhoea
◦ Paracetamol for headaches and muscle pain if no liver damage
Nicotine and other tobacco components may interact with and affect action and metabolism of certain medication e.g. clozapine and olanzepine – upon cessation of smoking patients may develop drug side-effects - consider revising dosages
After smoking cessation caffeine is absorbed more readily – increased caffeine levels increase restlessness and sleep disturbance
Start hours after last cigarette, peak in 24 –72 hours, decline and resolve within 2 – 4 weeks
Dysphoric or depressed mood
Insomnia
Irritability, frustration or anger
Difficulty concentrating
Restlessness
Decreased heart rate
Increased appetite or weight gain
Nicotine replacement therapy
Available as patches, gum, inhalers and lozenges, gel
Dosage depends on amount of cigarettes smoked before stopping
Combinations may be used in patients with high nicotine tolerance
Schuckit MA. Alcohol and Alcoholism in Kasper BL, Braunwald E et al (eds), Harrison’s Principles of Internal Medicine, 16th ed, McGraw Hill, New York, 2006, p. 2562-2566
Burns DM. Nicotine Addiction in Kasper BL, Braunwald E et al (eds), Harrison’s Principles of Internal Medicine, 16th ed, McGraw Hill, New York, 2006, p. 2573-2576
Kosten TR, O’Connor PG. Management of drug and alcohol withdrawal. N Eng J Med 2003;348(18):1786-1795
Eyer F et al. Alcohol Alcohol 2011;46(4):427-433 McKeown N. Withdrawal Syndromes. Available from URL:
http://emedicine.medscape.com/article/819502-overview#showall
NorthWestern Mental Health. Alcohol and Other Drug Withdrawal Practice Guidelines.
Australian Alcohol and Drug Abuse Management Guidelines