Managing Alcohol and Opioid
Withdrawals
Pouneh Nasseri MD
Chief resident
Goals of lecture
• Recognize alcohol and opioid withdrawal in
the inpatient setting
• Management of withdrawal in the inpatient
setting
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 symptoms
• MINOR WITHDRAWAL SYMPTOMS
– Insomnia
– Tremulousness
– Mild anxiety
– Gastrointestinal upset
– Headache
– Diaphoresis
– Palpitations
Alcohol Withdrawal
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
• Consider PPX in asymptomatic patients who
have high risk factors for DT and withdrawal.
• 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
Opioid Withdrawal
• Sign 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 of 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
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