Managing Alcohol and Opioid
Withdrawals
Shyam Rao, MD
Chief resident
Adapted From:
Pouneh Nasseri MD
Goals of lecture
• Understand alcohol withdrawal physiology
• Recognize alcohol withdrawal and
management of withdrawal in patient setting
• Management and recognition of inpatient
opioid withdrawal
• Treatment of cocaine withdrawal
Common Presentation
• 55 year old male presents to the ER with
generalized tremors. He is anxious, pacing the
hallways and also nauseous. Initial vital signs
indicate hypertension and tachycardia. During
the interview, he admits to heavy alcohol use
and that he is trying to cut down. His last drink
was about 6 hours ago.
Alcohol use terminology
Standard drink
Equivalents:
Approximate # of standard drinks in:
Recognizing alcoholism
• Terms used: alcohol abuse, alcohol dependence, alcohol
use disorder
Typical characteristics
• Impaired control over drinking
• Preoccupation with alcohol
• Use of alcohol despite adverse consequences
• Distortions in thinking, most notably denial
Different screening tools:
• CAGE
• Alcohol use disorder identification Test (AUDIT) or AUDIT-C
How many drinks
are too many?
• The National Institute on Alcohol Abuse and
Alcoholism (NIAAA) definition:
• Men under age 65
– More than 14 standard drinks per week on
average
– More than 4 drinks on any day
• Women, adults 65 years and older
– More than 7 standard drinks per week on average
– More than 3 drinks on any day
Alcohol Withdrawal Pathophysiology
• ETOH = Depressant
• Sudden cessation causes CNS hyperactivity
• Enhances inhibitory tone (via modulation of
gamma-aminobutyric acid activity)
• Inhibits excitatory tone (via modulation of
excitatory amino acid activity).
Alcohol Withdrawal
Alcohol withdrawal symptoms
• MINOR WITHDRAWAL SYMPTOMS
– Insomnia
– Tremulousness
– Mild anxiety
– Gastrointestinal upset
– Headache
– Diaphoresis
– Palpitations
ETOH Withdrawal and timeline
Delirium Tremens
• Defined as: Hallucinations, disorientation,
altered mental status, tachycardia,
hypertension, fever, agitation, and diaphoresis
• Can start from 48-96 hours from last drink
• Could last from 1-7 days
• Mortality of 5%
Risk factors for Delirium Tremens
• History of DT
• Age > 30
• Longer period of
drinking
• Multiple medical
illness
• Significant alcohol
withdrawal despite
high ETOH level
• A longer period
since the last drink
Management of ETOH Withdrawal
• Alleviating symptoms of psychomotor agitation
• Volume deficit replacement: Hypovolemic
• Correcting metabolic derangements
– Electrolyte imbalance : Potassium, Magnesium ,
Phosphorous
– Ketoacidosis
• Vitamin deficiencies: Wernicke’s encephalopathy.
Give Thiamine with glucose.
• Protein calorie malnutrition
Supportive care
• GI absorption can be impaired so using IV in
the first 2 days is helpful
• Banana bag: D5NS with thiamine, folate, and a
multivitamin
• If intoxicated and severe withdrawal consider
NPO initially to avoid aspiration
Treatment of psychomotor agitation
CIWA- Ar
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Nausea/Vomiting (0-7)
Headache(0-7)
Paroxysmal sweating (0-7)
Anxiety (0-7)
Auditory disturbances (0-7)
Visual disturbances (0-7)
Agitation (0-7)
Tremor (0-7)
Tactile Disturbances (0-7)
Orientation and clouding of sensorium (0-4)
CIWA-Ar
• Symptom triggered therapy
– < 10 : Very Mild withdrawal
– 10-15: Mild withdrawal
– 16-20: Modest withdrawal
– >20 : severe withdrawal
• Start treatment at CIWA score > 8
Benzodiazepines
• Diazepam (Valium) 5-10 mg IV every 5-10min
• Lorazepam (Ativan ) 2-4 mg IV every 10-20
min
• Chlordiazepoxide (Librium) (should be used in
PPX)
• Should be given IV in modest-severe
withdrawal
• Dosing: depends on comorbid conditions
Prophylaxis
• Asymptomatic patients who are high risk
• Librium taper: 50 to 100 mg POq6hrs for one
day and then 25 to 50 mg Q6hrs for 2 days.
• Can use Librium for very mild withdrawal in
low risk patient 25-50 mg PO as needed
Q1hrs.
Other treatments
• Ethanol
• Antipsychotics (such as Haldol)
• Anticonvulsants ( such as phenobarbital,
Carbamazepine)
• Centrally acting alpha-2 (Such as Clonidine)
• Beta blockers (Such as Propranolol)
• Baclofen
ICU Admission
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Age>40
Cardiac Disease
Marked acid-base disturbances
Severe electrolytes abnormalities
Respiratory insufficiency
Signs of gastrointestinal pathology
ICU Admission
• Evidence of rhabdomyolysis and hyperthermia
• Prior history of alcohol withdrawal
• Evidence of withdrawal with elevated alcohol
level
• High amounts of sedatives
Alcohol Withdrawal
• Remains a clinical diagnosis but consider other
diagnosis
• Spectrum of symptoms with DTs as life
threatening
• Requires medical treatment and observation
• ICU admission may be necessary for some
patients
• Oral benzodiazepines may be acceptable for
asymptomatic or minimally symptomatic
Opioid Withdrawal
• Signs and symptoms can start within 6-12
hour after short acting opioid and 24-48 hrs
after Methadone
• History can help you diagnose.
• Severity of symptoms depends on duration,
dose of opioid and if there is a iatrogenic
withdrawal
Opioid withdrawal
• Natural opioid withdrawal is not life threating
• Iatrogenic withdrawal can be dangerous:
– reversal agent such as Naloxone or naltrexone can
produce sudden surges in catecholamines and
hemodynamic instability
Opioid withdrawal
Opioid withdrawal
• Opioid agonist therapy: if they missed a dose
or two
• Methadone:
– 10 mg IM or Methadone 20 mg PO if they can
tolerate PO
• Buprenorphine
Opioid withdrawal
• Non-opioid adjunctive medications
• Alpha 2 antagonist Clonidine: 0.1 to 0.3 mg
every hour as needed
• Benzodiazepine: Diazepam 10-20 mg IV q515min PRN
• Phenegran: 25 mg IV or PO
• Loperamide
• Octerotide
Cocaine
• Allow the patient to sleep and eat
• Bromocriptine and amantadine are
theoretically supposed to work
• Propanolol: may aggravate coronary
vasoconstriction
• Lorazepam for supportive care
Question
• A 39-year-old man is admitted to the hospital for newonset agitation, fluctuating level of consciousness, and
tremors. He is diagnosed with acute alcoholic hepatitis.
• On physical examination, temperature is 38.8 °C (101.8 °F),
blood pressure is 95/55 mm Hg, pulse rate is 130/min, and
respiration rate is 30/min. Jaundice is noted. The abdomen
is protuberant with ascites but is soft, with no abdominal
rigidity or guarding. There is no blood in the stool. The
patient is agitated and disoriented, is unable to maintain
attention, and appears to be having visual hallucinations.
He believes that the nurse has stolen his wallet (which is in
his bedside drawer) in order to obtain his identity. He is
diaphoretic and tremulous. Asterixis is absent, and the
remainder of the neurologic examination is normal.
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A) Ceftriaxone
B) CT of head
C)Haldol
D) Lactulose enema
E) Lorazepam
• 72 yo female with a history pancreatic cancer
is admitted for worsening abdominal pain. She
is chronic opioids including methadone for
pain control. During this admission the
patient’s pain regimen was changed and
dosage increased. Overnight, the patient
became somnolent with respiratory
depression and narcan was given. What is the
best approach to deal with the patient’s
symptoms?
Summary
• Inpatient alcohol and drug withdrawal should
be taken seriously and may be life threatening
• Benzodiazepines are commonly used
medications for alcohol withdrawal for
supportive care
• Iatrogenic opioid withdrawal may be life
threatening
• Opioids and other adjunctive therapy may be
used for opioid withdrawal