Alcohol Withdrawal –
- Tremors start around 6 hours, seizures around 12 hours, but can occur 3-5 days later.
- Mortality can be as high as 35%.
- 3 Ts – Increase temp, tremor and tachycardia
- Treatment: correct electrolyte imbalances, benzos, can use propofol or barbiturates in refractory cases, magnesium, alpha 2 agonists, Beta blockers, calcium channel blockers
- Avoid: tramadol, meperidine, Thorazine, bupropion, TCAs, fluoroquinolones, carbapenems, theophylline, romazicon (huge risk of seizure in chronic user)
- Use Clinical Institute Withdrawal Assessment for Alcohol scale (CIWA-Ar): 0-67, higher is worse. Treat if 8-10.
- Benzos are main treatment:
- Lorazepam: 2-4 mg every 6 hours (preferred, no active metabolites, no liver interactions)
- Diazepam: 10-20 mg every 5 hours (lower in liver failure)
- Chlordiazepoxide: 50-100 mg every 6 hours (long-acting, decrease dose in liver issues
- Thiamine: prevent Wernicke-Korsakoff syndrome
- Magnesium: Check labs to see if needed
- Electrolyte labs, such as potassium
- Vitamins: Patients are usually undernourished
- Fluid therapy: patients are initially overhydrated, then dehydrated, usually give 5% dextrose
- Hallucinations can be controlled by BZDs or haloperidol
- Beta-blockers: can control tremor, heart rate and blood pressure
- Alpha-agonist: clonidine can help with withdrawal
- Can use disulfiram, naltrexone, acamprosate for chronic therapy. All are liver toxic. Naltrexone is better in liver dysfunction.
Opioid Dependence –
- Maintenance with methadone, naltrexone, buprenorphine. Opioid withdrawal is not fatal (flu-like symptoms). Methadone must be tapered to 30 mg daily or less before discontinued.
- 10+ cigarettes a day = 21 mg patch, decrease in 2 weeks
- <10 cigarettes a day = 14 mg patch, decrease in 6 weeks
- Gum: max = 24 pieces a day, use at least 9 pieces per day. > 24 cigarettes a day = 4mg gum, all others use 2 mg gum
- Lozenges – people who smoke within 30 minutes of waking use 4 mg, all others use 2 mg.
- Bupropion – start at least 7 days before quitting. Treat at least 8 weeks, up to 6 months.
- Varenicline: start 7 days prior to quitting, use at least 12 weeks (can use up to 24 weeks). Black box warning for psychosis. Can be combined with bupropion or a patch.